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DISEASES OF CHILDREN 



BY 



EDWIN E. GRAHAM, A.B., M.D. 

PROFESSOR OF DISEASES OF CHILDREN IN THE JEFFERSON MEDICAL COLLEGE; PEDIATRIST 

TO THE JEFFERSON MEDICAL COLLEGE HOSPITAL AND TO THE PHILADELPHIA GENERAL 

HOSPITAL, PHILADELPHIA; CONSULTING PEDIATRIST TO THE TRAINING SCHOOL 

FOR THE FEEBLE-MINDED AT VINELAND, N. J.; MEMBER OF THE 

AMERICAN PEDIATRIC SOCIETY, ETC. 



HUustrateD witb S9 enaravtncjs anO 4 flMates 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1916 



r 7<T 



Entered according to the Act of Congress, in the year 1916, by 

LEA & FEBIGER, 
in the Office of the Librarian of Congress. All rights reserved. 



H 



£2- 

1916 



©CI.A438468 



TO 

THE MEMORY OF MY 
BROTHER 

JAMES GRAHAM, M.D. 



PREFACE. 



In the preparation of this work the aim of the author has been to 
make it represent the most modern views upon each subject discussed, 
and to present these views in such a way that they may be immediately 
available to the busy practitioner as well as easily intelligible to the 
medical student. 

The treatment of each disease is given in full, and the physician 
engaged in general practice will find herein the precise management of 
a typical case of any disease which he is called upon to treat. In 
addition, the clinical examination of the sick child is carefully con- 
sidered, and its anatomy and physiology are discussed in detail. 

In the consideration of each subject a special effort has been made 
to make the book thoroughly up to date, and to each chapter has been 
allotted the amount of space its importance appeared to warrant, 
only a few of the rarest diseases having been omitted. As, however, 
the book has been written from the practical, and not from the theo- 
retical standpoint, recent and unconfirmed suggestions and theories 
have not, as a rule, been considered. 

Sufficient space has been devoted to pathology, and a larger amount, 
proportionately, to symptoms, diagnosis, and treatment. The illus- 
trations and .r-ray plates are all from the author's private and hospital 
cases, except where credit has been given to others. 

From long experience in teaching both students and practitioners, it 
has seemed to the author most important that the processes of normal 
digestion be thoroughly understood before any attempt be made to 
study the various disturbances and diseases of the gastro-intestinal 
tract, hence the subject of normal digestion has been considered in a 
special chapter. 

The subject of infant feeding has received particular attention; 
the construction of milk mixtures, usually a vague subject to both the 
general practitioner and the student, is carefully explained, and the 
calculation of caloric and percentage feeding has been illustrated by 
formulas reduced to ounces. 



vi PREFACE 

Diseases of the gastrointestinal tract have been presented in full, and 
some of the most advanced ideas concerning diagnosis and treatment 
have been incorporated. Food injuries, chronic constipation, pyloro- 
spasm, and pyloric stenosis have received special consideration, a 
careful differentiation being made between the two latter affections. 

Special features of the book to which the author desires to call the 
attention of the reader are the chapters on Infant Mortality, Heredity 
and Environment, Puberty, Fresh Air, and Diseases of the Liver, 
Spleen, and Thymus Gland. To each of these subjects is allotted a 
special chapter in view of their ever-increasing importance to the 
practising physician. 

The Diseases of the Nervous System have been discussed in eighty 
pages. A careful consideration of these diseases belongs in a book on 
Pediatrics, and the physician interested in children will find here a 
broad field for study. To Infantile Paralysis the author has devoted 
ten of these pages. 

A special chapter has been devoted to Dentition, for the author 
regards this as a normal and physiological process in the course of 
normal development. Particular attention is also called to the articles 
on Diphtheria, Influenza, Pertussis, Poliomyelitis, and Enlargement 
of the Thymus Gland. 

The author here acknowledges his indebtedness to the following 
physicians connected with the Pediatric Department at Jefferson 
Medical College: Dr. Julius Blechschmidt, Dr. R. L. Engle, Dr. 
Joseph Fleitas, and Dr. W. H. Johnston. 

I wish to express my appreciation to my publishers, Messrs. Lea & 
Febiger, for their earnest cooperation during the entire period of the 
book's preparation. 

E. E. G. 
Philadelphia, 1916. 



CONTENTS. 



CHAPTER I. 



The Normal Infant at Birth. 

General Appearance 17 

Circulatory System 18 

Digestive System 19 

Respiratory System 20 

Ductless Glands 20 

Genito-urinary System 20 

Nervous System 21 

Mammary Glands 21 

Temperature 21 

Care of the Newborn 21 

Bathing 21 

Clothing 22 

Sleep 23 

Exercise 24 

Fresh Air 25 

Vaccination 27 



CHAPTER II. 

Normal Development of the Child. 

Height 30 

Weight 30 

Head 34 

Neck 35 

Spine 35 

Thymus Gland 35 

Thorax 36 

Fetal Circulation 37 

Pulse 39 

Respiration 39 

Temperature 40 

Muscular Development 41 

Nervous System 42 

Special Senses 43 

Stomach 44 

Intestine 45 



vin CONTENTS 

CHAPTER III. 

The Clinical Examination of Sick Children. 

Family History 46 

Inspection 46 

Palpation 47 

Auscultation 48 

Percussion 49 

Mensuration 49 

CHAPTER IV. 

Infant Mortality. 

General Statistics . . . . 50 

CHAPTER V. 

Heredity $8 

CHAPTER VI. 

Congenital Malformations. 

Brain and Spinal Cord 72 

Meningocele 72 

Encephalocele 74 

Hydrencephalocele 74 

Acute Hydrocephalus 75 

Chronic External Hydrocephalus 75 

Chronic Internal Hydrocephalus 75 

Caput Succedaneum 78 

Cephalhematoma 78 

Anencephalia 80 

Hare-lip and Cleft Palate 82 

Hare-lip 82 

Cleft Palate 84 

Congenital Malformations of the Tongue 85 

Tongue-tie 85 

Macroglossia 86 

Ranula' . . ' . . . . . . . 86 

Congenital Diseases of the Neck 86 

Fistulse of the Neck 86 

Congenital Cystic Lymphangioma of the Neck 87 

Congenital Torticollis 87 

Congenital Malformations of the Esophagus 88 

Meckel's Diverticulum 88 

Hernia of the Umbilical Cord . 90 

Umbilical Hernia 90 



CONTEXTS IX 

Congenital Dilatation of the Colon 92 

Atresia of the Bowel 93 

Malposition of the Bowel 95 

Exstrophy of the Bladder 96 

Undescended Testes; Cryptorchidism 97 

Hydrocele 98 

Congenital Hydrocele 98 

Hydrocele of the Tunica Vaginalis 98 

Encysted Hydrocele of the Cord 98 

Obliteration of the Bile Ducts 99 

Spina Bifida 100 

Spinal Meningocele 100 

Myelomeningocele 101 

Myelocystocele 101 

Spina Bifida Occulta « 101 

Atresia of the Vagina, Labia, and Urethra 103 

Hypospadias and Epispadias 104 



CHAPTER VII. 

Diseases of the Newborn. 

Prenatal Paralysis 105 

Xatal paralysis 106 

Birth Palsies 108 

Erb's Palsy (Obstetric Paralysis) 10S 

Klumpke's Palsy 110 

Facial Palsy Ill 

Albuminuria and Uric Acid Infarction Ill 

Bone Injuries 112 

Asphyxia of the Newborn 112 

Asphyxia Cyanotica 113 

Asphyxia Pallida 113 

Atelectasis 115 

Mastitis 117 

Icterus Neonatorum 118 

Acute Septic Infection of the Newborn 120 

Diseases of the Umbilicus 124 

Omphalitis 124 

Gangrene of the Cord 125 

Gangrene of the Umbilicus 125 

Umbilical Hemorrhage 125 

Hemorrhage in the Newborn 126 

Hemorrhagic Disease of the Newborn 126 

Acute Fatty Degeneration of the Newborn (Buhl's Disease) .... 12S 

Epidemic Hemoglobinuria (Winckel's Disease) 12S 

Melena Neonatorum 129 

Erysipelas 131 

Tetanus (Trismus Neonatorum) 133 

Sclerema 135 

Sclero-edema 136 

Achondroplasia (Chondrodystrophy — Microlelia) 138 



CONTENTS 



CHAPTER VIII. 

Infant Feeding. 

Cow's Milk 141 

Bacteria in Milk 142 

The Souring of Milk 143 

The Preservation of Milk 143 

Sterilization 144 

Pasteurization 145 

Concerning the Feeding of Sterilized, Pasteurized, or Raw Milk . . 146 

Peptonization 148 

Diluents 149 

Water 149 

Cereal Diluents 149 

Alkaline Diluents 150 

Condensed Milk 150 

The Food Materials Used in Infant Feeding .151 

Water 153 

Protein 154 

Fats 155 

Carbohydrates 156 

Mineral Salts 157 

Breast Feeding 158 

[Mammary Gland 159 

Frequency of Breast Feeding 160 

Human Milk 161 

Advantages of Breast Feeding 161 

Wet Nurse 165 

Alexins 166 

Percentage Feeding 167 

Modification of Milk 167 

Calculation of Percentages 172 

Amount of Cream in Milk 173 

Albumin Milk: Eweissmilch: Protein Milk 173 

Buttermilk 174 

Whey 175 

Proprietary Foods 176 

Meat Preparations 177 

Malt Soup 178 

Artificial Feeding 178 

Fats 178 

Carbohydrates 179 

Milk Sugar 179 

Cane Sugar 179 

Starch 179 

Proteins 179 

Caloric Feeding 179 

Home Modification of Milk 180 

Laboratory Method of Modification of Milk 181 

Feeding after the Weaning Period 183 

Care of Bottles and Nipples 183 



CONTENTS xi 



CHAPTER IX. 



Normal Digestion. 

The Oral Cavity 184 

Gastric Digestion 185 

Anatomical and Physiological Peculiarities 186 

Absorption in the Stomach 190 

Anatomical and Physiological Peculiarities of the Intestines 190 

Succus Entericus 192 

Absorption in the Intestines 193 

Bacteria 195 

Fat Indigestion 199 

Carbohydrates 200 

Protein Indigestion 201 

Disturbance of Balance 205 

Dyspepsia 206 

Alimentary Intoxication 207 

Feces 209 

Composition 211 



CHAPTER X. 
Fresh Air in the Treatment of Disease .... 212 

CHAPTER XI. 

Dentition 217 



CHAPTER XII. 

Rickets. 

General Considerations 227 

Congenital Rickets 245 

Adolescent, or Late, Rickets 245 

Acute Rickets 245 



CHAPTER XIII. 

Diseases of the Gastro-intestinal Tract. 

Diseases of the Lips 246 

Herpes 246 

Perleche . 247 

Diseases of the Tongue 248 

Geographical Tongue 248 

Glossitis 248 

Microglossia 249 

Macroglossia 249 



xii • CONTENTS 

Diseases of the Mouth 249 

Alveolar Abscess 249 

Ulcer of the Frenum 250 

Bednar's Aphthae ♦ . 250 

Catarrhal Stomatitis 251 

Aphthous Stomatitis (Herpetic Stomatitis) 252 

Thrush^Sprue 253 

Ulcerative Stomatitis 255 

Gangrenous Stomatitis 257 

s Pyorrhea Alveolaris 260 

Uvulitis .260 

Diseases of the Esophagus 261 

Esophagitis 261 

Retro-esophageal Abscess 262 

Diseases of the Stomach and Intestines 263 

Vomiting 263 

In Early Infancy 263 

Symptomatic Vomiting 263 

Cyclic Vomiting 264 

Gastralgia • 266 

Indigestion 267 

Fat Indigestion 267 

Carbohydrate Indigestion 269 

Protein Indigestion . 271 

Feces 273 

Acute Gastric Indigestion . . . . 274 

Acute Gastritis 275 

Gastroduodenitis 279 

Acute Gastro-enteritis — Summer Diarrhea — Summer Complaint . 279 

Acute Enterocolitis 287 

Dysentery 289 

Cholera Infantum . . 292 

Chronic Gastritis 295 

Dilatation of the Stomach 299 

Pylorospasm 301 

Hypertrophic Pyloric Stenosis 305 

Pyloric Stenosis in Older Children 308 

Enteralgia, or Colic 312 

Hematemesis 314 

Gastric Ulcer 314 

Chronic Intestinal Indigestion . . .316 

Chronic Ileocolitis 320 

Intussusception 323 

Chronic Constipation 326 

Incontinence of Feces 330 

Diarrhea ' . 331 

Intestinal Bacteria 332 

Mucous Colitis 333 

Amyloid Disease of the Intestines 334 

Intestinal Obstruction 334 

Volvulus 335 

Appendicitis 335 

Gangrenous Appendicitis 338 

Chronic Appendicitis 339 



CONTENTS xiii 

Diseases of the Stomach and Intestines — 

Int&stinal Worms 341 

Cestodes 341 

Taeniae, or Tapeworms 341 

Taenia Solium, or Pork Tapeworm 342 

Taenia Mediocanellata, or Beef Tapeworm 342 

Bothriocephalus Latus, or Fish Tapeworm .... 342 

Dwarf Tapeworm — Taenia Nana 342 

Nematodes 344 

Oxyuris Vermicularis — Threadworm 344 

Ascaris Lumbricoides — Roundworm 346 

• Trichocephalus Dispar 347 

Ankylostomum Duodenale — Hookworm 348 

Trichina 350 

Diseases of the Peritoneum 351 

Acute Peritonitis 351 

Chronic Peritonitis 354 

Ascites 356 

Inguinal Hernia 358 

Diseases of the Rectum and Anus 361 

Proctitis 361 

Prolapse of the Rectum (Procedentia Recti) 362 

Rectal Polypi 364 

Hemorrhoids 365 

Fissure in Ano 365 

Spasm of the Anus 366 

AnalFistulae 366 

Ischiorectal Abscess 367 

Diseases of the Liver 36S 

Size and Location of the Liver 368 

Bile 369 

Jaundice or Icterus 369 

Obstructive Jaundice 369 

Hematogenic Jaundice 371 

Congestion of the Liver 372 

Enlargement of the Liver 373 

Congenital Acholuric Jaundice 373 

Congenital Obliteration of the Bile Ducts 375 

Stenosis of the Bile Ducts 376 

Acute Yellow Atrophy of the Liver 376 

Cholelithiasis 378 

Abscess of the Liver 378 

Subphrenic Abscess 379 

Functional Disorders of the Liver 380 

Cirrhosis of the Liver 381 

Amyloid Liver 3S4 

Fatty Liver 385 

Tuberculosis of the Liver 386 

Syphilis of the Liver 3S7 

Tumors of the Liver 388 

Cysts of the Liver 389 

Diseases of the Pancreas 389 

Acute Pancreatitis 3S9 

Chronic Pancreatitis 390 

Tuberculosis of the Pancreas 390 



xiv CONTENTS 



CHAPTER XIV. 

Diseases of the Respiratory Tract. 

Anomalies 391 

Diseases of the Nasopharynx 391 

Acute Rhinitis 391 

Chronic Rhinitis 394 

Atrophic Rhinitis «... 395 

Purulent Rhinitis 395 

Epistaxis 395 

Adenoids 396 

Diseases of the Larynx 400 

Acute Laryngitis (False Croup — Spasmodic Croup) 400 

Edema of the Larynx (Glottis) and the Submucous Membrane . . . 402 

Serous Infiltration . 402 

Inflammatory Edema 403 

Laryngismus Stridulus (Child-crowing) . *. 404 

Congenital Laryngeal Stridor 405 

New Growths of the Larynx 406 

Foreign Bodies in the Larynx, the Trachea, and the Bronchi . . . 407 

Diseases of the Bronchi 408 

Acute Bronchitis 408 

Diseases of the Lungs 414 

Pneumonia 414 

Lobar Pneumonia 414 

Bronchopneumonia 423 

Diseases of the Pleura 430 

Pleurisy — Serous and Purulent 430 

Reflex Cough . 438 

Asthma 439 

Abscesses of the Lung 442 

Gangrene of the Lung 442 

Acquired Atelectasis, or Pulmonary Collapse 443 

Emphysema 444 

CHAPTER XV. 

Diseases op the Heart. 

The Heart . • 445 

The Pulse 446 

The Apex Beat 446 

Murmurs 447 

1. Pulmonary Systolic Murmurs 448 

2. Cardiopulmonary Murmurs 448 

3. Intracardiac Murmurs 449 

Congenital Diseases of the Heart 450 

I. Abnormal Persistence of Fetal Conditions 452 

II. Deformities of Valves 453 

III. Abnormalities of Vessels and of the Cavities of the Heart . . 454 

Physical Examination in Diseases of the Heart 454 

Palpation 455 

Percussion 455 

Auscultation 456 



CONTENTS XV 

The General Symptoms of Heart Disease 456 

Acute Endocarditis 457 

Chronic Endocarditis, or Acquired Valvular Disease 461 

Acute Pericarditis 465 

Adherent Pericarditis 467 

Myocarditis 469 

CHAPTER XVI. 
Diseases of the Blood. 

The Blood in Infancy and Childhood 172 

Physical Properties 472 

Hemoglobin 472 

Red Cells 472 

Leukocytes 473 

Blood Platelets 475 

Blood Dust 475 

Anemia 475 

Secondary, orSimple, Anemia 475 

The Primary Anemias 476 

Chlorosis 476 

Pernicious Anemia 478 

Leukemia 479 

Pseudoleukemia of Infants (von Jaksch) 481 

Splenic Anemia (Banti's Disease) 483 

Lymphatic Anemia (Pseudoleukemia: Hodgkin's Disease) 484 

Hemorrhagic Diseases 487 

Hemophilia (Bleeder's Disease) 487 

Purpura 489 

Purpura Simplex 490 

Purpura Hemorrhagica 491 

Purpura Rheumatica 492 

Henoch's Purpura 492 



CHAPTER XVII. 

Diseases of the Ductless Glands. 

Splenitis ■ 493 

Perisplenitis 494 

Abscess of the Spleen 494 

Wandering Spleen 494 

Primary Splenomegaly 495 

New Growths of the Spleen 495 

Diseases of the Lymph Glands 495 

Simple Acute Adenitis 495 

Simple Chronic Adenitis 497 

Tuberculous Adenitis 498 

Diseases of the Thymus Gland 499 

Atrophy of the Thymus 504 

Enlargement of the Thymus 504 

Status Lymphaticus 507 



xvi CONTENTS 

Diseases of the Thyroid Gland 508 

Goitre 508 

Exophthalmic Goitre (Graves's Disease) 509 

Cretinism 510 

Diseases of the Adrenal Glands 514 

Addison's Disease 514 

The Pineal Gland 516 

The Pituitary Gland . 516 

CHAPTER XVIII. 

Diseases of the Bones and Joints. 

Acute Infectious Osteomyelitis 517 

Tuberculosis of Bones - ' . 518 

Syphilis of Bones 519 

Dactylitis 520 

Craniotabes ' 521 

Bossing of the Skull 522 

Acute Arthritis of Infants 522 

Tuberculosis of Joints > ■ . • • • • 523 

CHAPTER XIX. 

Diseased op the Genito-tjrinary System. 

Diseases of the Kidney 525 

The Urine 525 

Hematuria 526 

Hemoglobinuria 527 

Functional Albuminuria (Postural, Cyclic, and Orthotic Albuminuria) 527 

Paroxysmal Albuminuria '. . 528 

Lithuria 528 

Acetonuria 529 

Indicanuria 530 

Glycosuria 530 

Fehling's Test 531 

Pyuria 531 

Dysuria 532 

Anuria 532 

Retention of Urine ■ 533 

Polyuria 534 

Enuresis 534 

Nephritis . . . . 538 

Acute Congestion of the Kidneys 539 

Nephritis in Infancy 539 

Acute Diffuse Nephritis 541 

Chronic Nephritis 547 

Chronic Parenchymatous Nephritis 548 

Perinephritis 551 

Tuberculosis of the Kidney 553 

Renal Calculi 554 

Tumors of the Kidneys 555 

Congenital Cystic Kidney 557 

Hydronephrosis 561 

Movable Kidney 562 



CONTENTS xvn 

Diseases of the Bladder 563 

Pyelitis 503 

Cystitis 567 

Vesical Spasm 568 

Vesical Calculi (Urethral Calculi) 569 

Urethritis 570 

Specific Urethritis 570 

Diseases of the Reproductive Organs 571 

Phimosis 571 

Paraphimosis 572 

Balanitis 572 

Torsion of the Spermatic Cord 572 

Acute Orchitis 573 

Tuberculous Orchitis 573 

Tumors of the Testicle 574 

Vulvovaginitis 575 

Simple Vulvovaginitis 575 

Gonorrheal Vulvovaginitis 576 

Gangrene of the Vulva 580 

Vicarious Menstruation 581 

Menstruation Precox 581 

Masturbation 582 

CHAPTER XX. 

Diseases of the Skin. 

Eczema 586 

Urticaria (Nettle Rash: Hives) 588 

Ichthyosis 589 

Intertrigo 590 

Impetigo Contagiosa 591 

Furunculosis 592 

Miliaria 593 

Erythema Multiforme 593 

Seborrhea 593 

Psoriasis 594 

Tinea 594 

Tinea Tonsurans 595 

Tinea Circinata 596 

Herpes 596 

Herpes Zoster (Shingles) 597 

Warts (Verrucae) 597 

Alopecia 598 

Alopecia Areata 598 

Naevi 600 

Gangrenous Dermatitis 601 

Pemphigus Neonatorum . 601 

Dermatitis Exfoliativa Neonatorum 602 

Molluscum Contagiosum 602 

Parasitic Skin Diseases 603 

Pediculosis 603 

Scabies 604 

Dermatitis Medicamentosa 605 

Tuberculosis Cutis ... 606 



xvni CONTENTS 

CHAPTER XXI. 

Diseases of the Eae. 

Foreign Bodies in the Ear . 607 

Acute Otitis Media 607 

Chronic Suppurative Otitis Media 4 612 

Acute Mastoiditis 614 

CHAPTER XXII. 

The Specific Infectious Diseases. 

Typhoid Fever 617 

Typhoid Fever in the Fetus 618 

Typhoid Fever in the Infant 619 

Typhoid Fever in the Older Child 620 

Parathyphoid Fever 627 

Scarlet Fever (Scarlatina) 628 

Varicella (Chicken-pox) 639 

Measles (Morbilli— Rubeola) 642 

Rubella (Rotheln — German Measles) 653 

Diphtheria 656 

Nasal Diphtheria 660 

Laryngeal Diphtheria, or Membranous Croup 665 

Pseudodiphtheria 686 

Pertussis (Whooping-cough) 688 

Mumps (Epidemic Parotitis) 699 

Influenza (La Grippe: Catarrhal Fever) 701 

Smallpox (Variola) 707 

Varioloid 710 

Abortive Types 710 

Vaccinia (Cow-pox) 713 

Vaccine Virus 714 

Humanized Virus 714 

Bovine Virus 715 

Vaccination 715 

Tuberculosis 717 

Pulmonary Forms 722 

Tuberculous Bronchopneumonia 722 

Miliary Tuberculosis 722 

Acute Miliary Tuberculosis 722 

Clinical Varieties 723 

Chronic Tuberculosis 725 

General Tuberculosis 726 

Tuberculosis of the Glands — Lymphatic Glands, Bronchial .... 726 

Cervical Glands 727 

Mesenteric Glands 727 

Pleura 727 

Heart 727 

Brain 728 

Liver 728 

Spleen 728 

Intestines 728 

Peritoneum 728 

Kidney 728 

Tuberculin Tests . 7 , ., ,,,.,, 729 



CONTENTS xix 

Malaria 732 

The Parasite 733 

Clinical Forms of Malaria 734 

Pernicious Malaria 736 

Syphilis 738 

Acquired Syphilis 738 

Hereditary Syphilis 739 

Early Syphilis 743 

Late Hereditary Syphilis 745 

CHAPTER XXIII. 

Rheumatism. 

Acute Articular Rheumatism 747 

Muscular Rheumatism 757 

Chronic Rheumatism 758 

Still's Disease 758 

Rheumatoid Arthritis — Arthritis Deformans 759 

CHAPTER XXIV. 

Scurvy 763 



CHAPTER XXV. 

The Nervous System. 

I. Introduction 769 

Morphology 769 

Histological Structure 769 

Physiological Development 770 

Psychological Development 771 

Peculiarities of the Nervous System of the Child 771 

II. Examination of the Nervous System 772 

Normal Reflexes 773 

Abnormal Reflexes 773 

Hypotonus 774 

Sensory Examination 774 

Electrical Examination 774 

Reaction of Degeneration 774 

III. Lumbar Puncture 775 

Pressure of the Spinal Fluid , 776 

Laboratory Examination 776 

IV. Cranial and Cerebral Puncture 778 

Diseases of the Spinal Cord 778 

Malformations 778 

Rachischisis 779 

Myelitis 779 

Transverse Myelitis 779 

Compression Myelitis 781 

Caries — Spondylitis Tuberculosa — Pott's Disease ..781 

Landry's Paralysis — Acute Ascending Paralysis 783 

Acute Anterior Poliomyelitis — Infantile Paralysis 784 

Cerebral and Abortive Types 791 



xx CONTENTS 

Diseases of the Spinal Cord — Acute Anterior Poliomyelitis — 

Progressive Muscular Atrophy . . . . 795 

Early Infantile Spinal 795 

Adult Form 796 

Amyotrophic Lateral Sclerosis 796 

Neural Form of Progressive Muscular Atrophy, Peroneal Type . 797 

Progressive Muscular Dystrophy 798 

Pseudohypertrophic Type 798 

Juvenile Type, Scapulohumeral 801 

Infantile Type, Facies-scapulohumeral 801 

Simple Atrophic Type, Hereditary 801 

Myotonia Congenita (Thomsen's Disease) 802 

Myotonia Congenita (Opphenheim) 803 

Syringomyelia 803 

Hereditary Ataxia (Friedreich's Ataxia) — Hereditary Cerebellar Ataxia 

(Marie) 804 

Spinal Form ' 805 

Tumors of the Spinal Cord 806 

Diseases of the Meninges 808 

Pachymeningitis 808 

Pachymeningitis Externa 808 

Pachymeningitis Interna 808 

Purulent Pachymeningitis Interna 808 

Pachymeningitis Interna Hemorrhagica 808 

Acute Suppurative Meningitis . . 810 

Pneumococcic Meningitis 812 

Septic, Streptococcic, and Staphylococcic Meningitis . . . .812 

Influenzal Meningitis 812 

Typhoid Meningitis 813 

Cerebrospinal Meningitis — Epidemic Meningitis 814 

Clinical Forms and Course 816 

Tuberculous Meningitis 819 

Atypical Cases . 822 

Diseases of the Brain , 824 

Cerebral Palsies 824 

Infantile Hemiplegia 825 

Cerebral Diplegia — Spastic Paraplegia — Little's Disease . . . 826 

Idiocy .828 

Amaurotic Family Idiocy 832 

Mongolian Idiocy 833 

Diseases of the Nerves 835 

Multiple Neuritis 835 

Diphtheritic Paralysis 836 

Postinfections (Non-diphtheritic) 838 

Toxic — Alcoholic, Lead, and Arsenical 839 

Facial Paralysis., 839 

Chorea 841 

Tetany 846 

CHAPTER XXVI. 

Puberty. 

Period Preceding Puberty 851 

Body 852 

Mind 855 



DISEASES OF CHILDREN. 



CHAPTER I. 
THE NORMAL INFANT AT BIRTH. 

General Appearance. — The physical proportions of the normal 
infant at birth show a striking contrast to those resulting after develop- 
mental adjustment. The head appears large in proportion to the size 
of the body; likewise, the shoulders, arms and upper chest, when 
compared with the pelvis and legs. 

The child's body is well rounded, being covered with a goodly layer 
of superficial fat. The head may be covered by a moderately thick 
growth of hair, although this is by no means always the case; strong, 
vigorous children showing not infrequently at birth a very small 
growth of hair. The head is often misshapen, as a result of pressure 
during labor. 

The face of the infant in the first few months of life is small in 
proportion to the cranium, and is as 1 to 8; at the age of five years, 
as 1 to 4; and in adult life as 1 to 2 or 2 J. The rapid growth of the 
inferior maxillary bone has much to do with the increased facial size. 
The chest of the infant is barrel shaped, the anteroposterior and 
transverse diameters being about the same. 

The abdomen is very prominent, being much larger proportionately 
than later in life. This is due to the large size of the liver in infants 
and the small size of the pelvis. 

The feet of the infant are distinctly arched, but this is not always 
apparent on account of the large amount of fat often present. 

The nails project beyond the fingers, their borders being very brittle. 

The color of the body immediately after birth is that of venous 
blood, as a result of stasis during the period of intra-uterine pressure. 
As this is removed, and respiration becomes established, the oxygen- 
ation of the blood soon manifests itself by a hyperemie redness, 
resulting within a few days in exfoliation which persists for about a 
week. 

Skin. — At birth the delicate integument of the infant is frequently 
covered with a material, the vernix caseosa, a secretion of its own 
sebaceous glands, with exfoliated epithelium and lanugo. The latter 
is the term applied to the soft, downy hair covering the body of the 
fetus, and persisting for a long time after birth. The sweat glands of 
the normal infant are comparatively inactive for several weeks after 
2 



IS THE NORMAL INFANT AT BIRTH 

birth, while the functional activity of the sebaceous glands is marked, 
often resulting in seborrhea of the scalp. The skin on the scalp is 
thicker than elsewhere on the body and adherent to the occipito- 
frontalis beneath it. 

Head. — At birth the head is capable of being easily molded, often 
resulting in elongation due to birth pressure, and frequently giving it 
a grotesque appearance. This plasticity, on the other hand, also 
permits of rapid adjustment of the cephalic contour, so that extensive 
disproportions often disappear soon after birth. The fontanelles, or 
membranous spaces between the bones of the skull, are the results of 
incomplete ossification, and are important landmarks in pediatrics 
as they are in obstetrics. 

The largest, the anterior fontanelle, is situated at the junction of the 
coronal, sagittal, and frontal sutures; it is rhomboid in outline, with 
the apex projecting anteriorly. 

The posterior fontanelle, triangular in shape, hardly exists as an 
opening at birth, the bones usually lying quite close together. The 
Wormian, or supernumerary bones, are frequently encountered along 
the sutures and at the fontanelles. 

The base of the skull in the newborn differs from that in the adult, 
in that there are no mastoid processes; on the other hand, the base 
of the skull is well ossified, notwithstanding that, during fetal develop- 
ment, the base of the skull is poor in ossification as compared to the 
vault. 

Thorax. — At birth the thorax is extremely compressible, the average 
circumference of the chest being thirteen inches. The clavicle is the 
first bone to ossify, and also the one most frequently fractured during 
parturition. The humerus at birth is almost entirely ossified, although 
the extremities of the bone are composed chiefly of cartilage. 

The knee-joint is supplied with numerous bursa?, distributed among 
the tendinous attachments of the various muscles. 

Circulatory System. — At birth, the average w T eight of the heart is 
about two-thirds of an ounce. The thickness of the right ventricle 
is very nearly the same as that of the left, the ratio being 6 to 7. The 
left ventricle, however, grows very much more rapidly than the right, 
so that at the end. of the second year the ratio is 2 to 1, which is 
nearly that of the rest of childhood. 

In the fetus the connection between the pulmonary artery and the 
aorta is called the ductus arteriosus. There also exists an opening, 
the foramen ovale, between the auricles, and there is likewise a valve 
which guides the blood from the inferior vena cava through the foramen 
ovale. This valve becomes atrophied after the normal circulation of 
the child has become established. The fetal circulation is characterized 
by the fact that arterial blood flowing from the placenta enters the 
fetus by means of the umbilical vein. 

Post-natal Circulation. — The transition of the fetal circulation to 
that after birth is characterized by several well-defined features. 
As respiration becomes established, and the pulmonary circulation 



GENERAL APPEARANCE 19 

begins, the patulous foramen ovale and the ductus arteriosus gradually 
close, the expansion of the lungs and the filling of their bloodvessels 
inaugurating the independent circulation by reason of the effect of 

the increased blood-pressure in the aorta upon the valve-like ductus 
arteriosus. Furthermore, the blood which is emptied into the left 
side of the heart exerts a mechanical pressure upon the valve closing 
the foramen ovale. 

The interruption of the placental circulation, together with the 
ligation of the umbilical cord, finally causes an atrophy of the ductus 
venosus and umbilical veins, converting them into a strand of fibrous 
tissue, the round ligament of the liver. 

Arteries. — The relation between the size of the heart and the diameter 
of the arteries in the newborn is inverse to that of the adult. In the 
latter the heart is quite large compared to the diameter of the arteries, 
while in children the heart is small and the caliber of the arteries is 
large. It is manifest, therefore, that the blood-pressure in children i- 
relatively low; on the other hand, it is quite high in the pulmonary 
circulation, on account of the larger caliber of the pulmonary artery 
as compared to that of the ascending aorta. 

Blood. — After birth, and before ligation of the umbilical cord, a 
certain amount of blood enters the child, resulting in plethora. Soon 
after birth, however, an equilibrium is established, due to excretion 
of fluids and a concentration of the blood. There i> consequently a 
high color index, which soon disappears. The red blood corpuscles 
are present in all sizes, nucleated ones being frequently present for 
several days after birth. The blood of the newborn contains more 
leukocytes than that of the adult. The number of erythrocytes in the 
newborn and in very young children varies from 4,340,000 to 6,500,000. 

Pulse. — The activity of the circulation is very much more pronounced 
at birth and early infancy than in later life. It is estimated that the 
entire circulatory cycle in the infant is completed in twelve seconds. 
The pulse is slightly more frequent in females than in males. At 
birth, and even during infancy, a very rapid and irregular pulse may 
be compatible with good health; it may be noted even during sleep. 

Digestive System. — The organs of the digestive system in the new- 
born and in infancy possess peculiarities which markedly differentiate 
them from those of the adult. This is true not only of diseases of the>e 
structures, but is inherent in their anatomy and physiology. Among 
the most pronounced peculiarities of the mouth are the dryness and 
thinness of the oral mucous membrane, the deficiency of the salivary 
secretion at birth as well as its weakness in enzymosis. The absence 
of prehension is compensated by the suction produced by the lingual 
musculature and pressure of the cheeks. The stomach is small, almost 
vertical, and the fundus is practically undeveloped. 

The gastric juice contains essentially the constituents of that of the 
adult, while the pancreatic juice, on the other hand, is incomplete 
in its action on fats. The intestines are relatively longer than in the 
adult and poor in the development of Lieberkulm's and Brunner's glands. 



20 THE NORMAL INFANT AT BIRTH 

« 

The liver in the newborn is large and vascular, the volume being 
greater than that of the two lungs combined, the ratio not being 
reversed until the advent of puberty. The bile is poor in inorganic 
salts, excepting iron. 

Respiratory System. — The caliber of the nasal passage in the newborn 
is very small. The larynx is, likewise, very narrow, which is important 
to appreciate in considering intubation in an infant. The trachea at 
birth is flattened anteriorly and posteriorly, and remains so for some 
time, notwithstanding the distention from respiration. The surfaces 
of the cartilaginous rings are in apposition until the trachea becomes 
further developed. 

Lungs. — At birth the color of the lungs is a pinkish gray; the direct 
chemical action of the blood and the repeated inspiration of air soon 
changes that color to one of mottled gray and black. While before 
birth at full term the position of the lungs is toward the posterior 
portion of the thorax, the expansion induced by birth soon causes 
them to cover the pleural portion of the pericardium and occupy their 
permanent position in the thoracic cavity. The weight of the lungs 
before birth is 48 grams, while after the complete establishment of 
respiration their weight is increased to 80 grams. 

Ductless Glands. — The thymus gland in the newborn is situated in 
the anterior mediastinum behind the manubrium of the sternum, and 
reaches full development about the end of the second year. It is 
generally composed of two lobes which are in apposition in the middle 
line. After the second year it loses its identity by fat substitution, or 
entirely disappears. 

The thyroid gland in the newborn is relatively very large, the two 
lobes being united transversely by an isthmus. The parathyroids 
are present behind the lateral lobes of the thyroid gland. 

The bronchial glands, lymphatic in character, consist of several 
groups ; one in close relation with the trachea, another at the bifurca- 
tion of that structure; others at the roots of the lungs, known as 
the hilus glands, while still another group is in intimate relation with 
larger bronchioles as they enter the lungs. 

Genito-urinary System. — The kidneys of the newborn are relatively 
large and do not increase in size as much as the lungs or heart. At 
birth the kidneys are practically at the acme of their functional- capacity, 
and the suprarenals are relatively larger than in the adult and are 
extremely vascular. 

The bladder in the newborn is oviform in shape, the smaller end, 
being directed upward, the bladder descending as the pelvis develops. 
At birth the bladder is capable of holding from 2 to 4 drams. « 

Both the ovaries and testicles are at first abdominal organs, and only 
in the course of the development of the child, begin to occupy their 
respective positions. 

The uterus at birth is about one inch in length, and possesses no 
fundus. The cervix, on the other hand, is thicker and longer than the 
remaining portion. 



CARE OF THE NEWBORN 21 

Nervous System. In the newborn the nervous system is in a very 
rudimentary condition. The brain is large, watery, and very soft, 

and shows but little differentiation of gray and white matter. Likewise, 
the spinal cord is of soft consistency, the anterior horns being more 
fully developed than the other structures. 

Organs of Special Sense. — At birth, and for some time thereafter, the 
sclerotic coat of the eye has a bluish color, due to the underlying 
choroid being seen through the slightly transparent sclera. There is 
no coordination in the excursions of the extraocular muscles. The 
refraction of the eye at birth is usually hyperopic. The power of 
fixation is also absent. While the power of convergence may be present, 
it will not produce contraction of the pupil for some little time after 
birth. The color of the iris is usually blue or bluish gray. Photophobia 
in the presence of strong light is a constant characteristic of the newly 
bbrn. 

The ear and acuity of hearing in a newborn babe are very poorly 
developed, due to the shortness of the external meatus and the absence 
of bony formation. It is surprising, however, how soon the acuity of 
hearing in childhood reaches its acme. 

Taste. — This sense is very acute at birth, the newborn having been 
observed on frequent occasions to signify its appreciation or dislike 
for sweet or sour substances respectively. The slightest alteration 
in accustomed food is quickly detected in infancy, a bottle often 
being refused when there has been the smallest possible variation in 
an accustomed food mixture. 

Tactile Sensation. — This is developed at birth, more especially at 
the lips and tongue, where its utility is manifest for the purpose of 
nursing. 

Mammary Glands. — At birth the mammary glands are normally 
congested and somewhat swollen, and in many instances secrete a 
milk-white fluid. They are from one-third to one-fifth of an inch in 
diameter. 

Temperature. — The temperature of the newborn and of the young 
infant is exceedingly unstable. At birth the rectal temperature is 
from 98.4° to 100° F., fluctuating between these points for several 
weeks. The variation in the temperature is easily understood when 
one considers the large surface for radiation and the facility with which 
heat is disseminated from the easily dilated capillaries in the infant. 
A great many observations have shown that the temperature of infants 
begins to rise in the forenoon, reaches its fastigium in the course of the 
afternoon, and then declines. The temperature is at its minimum 
during the night and early morning hours, and at its maximum in the 
early afternoon. 

CARE OF THE NEWBORN. 

Bathing. — As soon as possible after birth the child should be bathed. 
In order that no delay may occur during the bath, all preparations 
should be made beforehand. The time of giving the bath should be 



22 THE NORMAL INFANT AT BIRTH 

fixed a1 a certain hour each morning, neither just before nor after 
feeding, nor immediately preceding the taking of the child out of 
doors. The temperature of the room should be 72° F. In winter, if 
possible, the child should be bathed before an open fire, care being 
taken not to place the infant in any line of draught. 

The best basin is the one divided in two portions, and supported 
at a convenient height by an iron frame. A small, fine sponge should 
be used to cleanse the face, corners of the eyes and ears; a small piece 
of soft linen or muslin to cleanse the nose. The head is now washed 
with pure castile soap, the soap cleansed off carefully and the head 
dried, the child's head, during this portion of the bath, being allowed 
to fall back on the hand of the nurse, care being taken to prevent soap 
getting in the eyes. The water in the other portion of the basin is now 
used on the body, with castile soap, special care being given the axilla?, 
groins, genitals, and anal region. 

The child is now quietly lowered into its tub — for infants the one of 
rubber, for older children the ordinary tin tub — and allowed to kick 
and move its body freely for two or three minutes. The baby is then 
rubbed and dried quickly with warm towels; its clothing being all 
previously arranged, it is quickly dressed and returned to its crib. 
This bath should be given every day, care being taken that the rubber 
tub does not become overheated, as severe burns may result from the 
baby being placed in the tub if the rubber has become too hot by being 
stationed near an open fire. 

The temperature of the bath is important, as a child's circulation 
is easily depressed, and coldness and blueness of the extremities easily 
produced. The temperature of the bath at different ages is shown in 
the following table : 

At birth, 98° F. 

At two weeks, 96° F. 

At one month, 94° F. 

At one month to six months, 92° F. 

Six months to one year, 90° F. 

One year to two and one-half 3 T ears, 86° F. 
The ordinary bath thermometer is easy to read even by an untrained 
nurse. It is protected by a wooden cover and does not sink; it is 
indispensable in a well conducted nursery. 

Clothing. — The clothing of all infants and children should be loose, 
especially around the neck, chest, abdomen, and pelvis. In order that 
the chest may develop properly and the normal action of the lungs be 
not restricted, it is absolutely essential that no compression whatever 
of the thorax be permitted. The proper performance of digestion, 
the motor activity of the stomach and intestines, and the normal 
circulation and functions of all the abdominal organs may be more 
or less interfered with unless quite loose garments are worn. The 
wearing of diapers tightly drawn and pinned is an undoubted factor 
in the development of pelvic deformities. 

All clothing should be supported from the shoulders and not from the 



CARE OF THE NEWBORN 2.°, 

clicsl or hips. Care must always be taken to keep the extremities 
warm, especially the hands and feet. 

The abdominal band can be dispensed with after the second month. 
The knitted binder fitting the body snugly and provided with arm- 
holes is the best form to use. 

In summer, gauze or very light flannel underwear is the best. A 
child must, however, be dressed with a view to its circulation; a thin 
delicate baby, with poor circulation, requires more clothing than one 
whose body is well covered with a plentiful supply of fat. 

At night, infants should wear a shirt of cotton or wool, a napkin, 
cotton stockings, and a long outer garment of light flannel, made with 
a drawing string or buttons at the bottom, and sufficiently wide 
not to confine the legs. This insures the lower extremities being 
covered during the night. 

The infant or long clothes consist of a binder worn during the first 
two months; shirt with sleeves, napkin, long stockings, flannel petti- 
coat, white petticoat, a long dress, and light flexible shoes or knitted 
socks. Diapers should not be too heavy or cumbersome; one of the 
best materials is birdseye. 

All shoes should be large, broad-toed, and made rights and lefts. 
If not so made the child's feet are turned from their normal line, the 
axis of the great toe changed, and the normal movement and growth 
of the feet impeded. A light and graceful step depends largely upon 
the strength and elasticity of the toes. The soles of children's shots 
should be flexible, for if stiff the active movements of the muscles of 
the feet are interfered with. These muscles are especially active in 
children. 

All clothing must be worn with due regard to climate and sudden 
changes in the weather. The tendency, undoubtedly, is to bundle 
children up too much. It is not advisable to change the weight of the 
underclothing too frequently. A heavier or lighter coat is a much 
better arrangement for changes in the temperature. In winter, the 
head, and, in quite cold weather, the ears, should be covered with a 
woolen cap. In summer, the ordinary hat of light straw with broad 
brim is the best. 

Sleep. — The bedroom should be large, airy, and sunny. The curtains 
should be of muslin or linen to insure easy and frequent washing. The 
light may be excluded by dark shades. All superfluous and heavy 
draperies should be dispensed with, and the floor covered with light, 
inexpensive rugs or carpet. 

The temperature of the infant's room should not fall below 60° F. 
during the night. The day nursery and sleeping apartment should 
always, if possible, be separate rooms. Each child should have a 
separate bed, and, if practicable, older children should room alone. 

During the first two months of life the child requires about twenty 
hours of sleep out of each twenty-four. As it grows older the amount of 
sleep required gradually becomes less. From the age of two months 
to six months, sixteen hours; at one year, fifteen hours; and at eighteen 



24 THE NORMAL INFANT AT BIRTH 

months, thirteen to fourteen hours. A child two and a half years old 
should sleep twelve hours, a portion of this being a nap during the day, 
and if possible this sleep during the day should be kept up until the 
child is Rve or six years old, and should be taken in the open air. At 
night the windows of the sleeping room should be kept wide open. 

Infants should be put to bed between six and seven o'clock; older 
children, between seven and eight o'clock. Regularity of sleeping 
should be instituted at birth, and much depends upon training. Healthy 
children, if kept in their own crib, in a quiet, dark room, not handled 
unnecessarily, and only disturbed to be fed, bathed, clothed, and to 
have soiled linen changed, will rarely fail to obtain the prescribed 
number of hours of sleep. 

Slight causes may, however, keep the child awake. An overheated 
or poorly ventilated room and too much bedclothing are among those 
causes most frequently overlooked. If there is decided restlessness 
in sleep, or a marked reduction in the amount of sleep, it usually 
indicates illness of some kind and should be carefully investigated. 

The crib should be provided with high sides or an inexpensive 
wooden fence, otherwise the child, after the tenth month, may be 
severely injured by falling out of its bed. A good set of springs, a 
moderately firm mattress, preferably of hair, and a small, flat hair 
pillow not over three inches thick is the best suited for the baby. 
The mattress, to be kept clean and sweet, must be protected by a 
rubber Jsheet. 

Exercise. — The infant if put in its crib without bed covering and its 
clothing loose will kick and move the arms vigorously, giving evidences 
of its pleasure by sounds as expressive as words. Occasionally, by 
placing the child on its abdomen the spine will be seen to bend 
vigorously and the head be bent backward, while the arms are often 
used to advantage. At the age of eight to nine months the infant 
usually begins to creep, a process that calls into action almost all the 
muscles of the body. 

When one year to fifteen months of age, infants usually stand alone 
and begin to walk. It is not wise to encourage the child to stand 
alone, or to assist it much in walking, unless one is sure that its failure 
to walk is due to its timidity, and not to lack of strength. Many 
delicate, rachitic children are left with more or less permanent bowing 
of the legs as the result of an overproud parent teaching his child 
to walk too soon. 

The habit of propping up in their coaches infants of twelve months 
or less is most unwise. The spinal column, being largely composed of 
cartilage at this age, is utterly unfitted to support the superimposed 
weight. As a result of this increased flexibility of the spine the child 
leans to one side, the spine becomes bent, and this unnatural position 
may be kept up for hours, the child even possibly falling asleep, and 
thus the foundation is often laid for a future spinal curvature. For 
the same reason, infants when carried should, if possible, be kept in a 
horizontal or semiprone position ; or if held more or less erect the back 



CARE OF THE NEWBORN 25 

should be well supported or the body allowed to fall forward against 
the chest and shoulders of the person holding it. 

The time when a baby should be taken outdoors depends largely 
upon the time of the year when it was born and the climate. A child 
born in the winter or fall in a climate such as Philadelphia, where the 
winters are moderately severe, should not be taken out before the age 
of two months. Then on mild, sunshiny days with little wind the baby 
may be taken out for a half to one hour, well bundled up in its coach, 
and its face protected by a veil. 

When tw r o months old, children may, for the same length of time, 
be wheeled in a coach in the nursery, dressed as if for outdoors, 
the windows being raised and all doors closed to avoid draughts. 
This makes the change from the nursery to the outside air less 
abrupt. , 

Children born in w r arm weather may be taken out when three weeks 
old. The eyes of all infants should be well protected by a parasol 
from the direct rays of the sun. It is safer to keep the baby indoors 
in damp weather, or on days when the thermometer falls below 20° F., 
especially if there is a strong wind. Older children usually get sufficient 
exercise in their play, which is to be preferred to long walks, the latter 
being often fatiguing. When possible, gardening is a most useful 
mode of exercise, each child having its own little plot for plants and 
flowers. 

A roof garden may be made to suit the purse of the poor or rich. 
If used in summer it is a great boon to those unable to keep their 
children for a long period out of the warm, close air of the city. It is 
also of great practical use in winter. 

Fresh Air.— The infant and young child should be given an abundance 
of fresh outside air, and if the child's normal bodily temperature is 
preserved, and the hands, feet, and ears kept warm, no injury from 
fresh outside air need be feared. It is always advisable, when 
possible, to protect the child from draughts, but a free circulation 
of air through the nursery and bedroom is always desirable. An open 
fireplace is of great advantage, insuring a withdrawal of air from the 
room. The window ventilator, consisting of a board fitting in the 
window with the pipes directed upward to admit fresh air, answers 
admirably. All rooms occupied by children should be thoroughly 
flushed out once a day, during the child's absence. 

A temperature of 66° to 70° F. is suitable for the nursery, the 
former being better than the latter. The child when six weeks old, 
warmly clad, may be taken into a room at 70° F., and, being carefully 
kept out of draughts, a window may be raised and the temperature 
allowed to fall to 60° F. This may be done for one hour, morning 
and afternoon. The temperature at tw T o months may be reduced 
to 50° F., and at the age of three months to 40° F. When the child 
is taken out of doors in cold weather a veil should always be worn, 
the hood of the baby carriage should always be kept raised, and the 
coach always turned so as to protect the infant from cold winds. Xo 



26 THE NORMAL INFANT AT BIRTH 

harm but great benefit results from these daily airing's, and the M 
prejudice about taking cold should not be considered. 

Hot water heating is cleanly, does not dry the air, and is to be 
preferred. If a hot-air furnace is used the radiators should be covered 
with cheesecloth. 

Eyes. — The eyes at birth, in the normal infant, are fully developed. 
As soon as possible after birth they should be well washed with 
a saturated solution of boric acid, and if any suspicious vaginal dis- 
charge is present in the mother a few drops of a solution of nitrate of 
silver, 2 grains to the ounce, should be carefully dropped into each 
eye and the eyes then washed with normal salt solution. The eye-wash 
of boric acid should always be used twice daily during the first week 
of life, as mild forms of conjunctivitis, non-gonorrheal in character, 
but caused by the entrance into the eyes of discharges from the vagina 
or rectum of the mother, are not uncommon. 

The mouth should be very gently cleansed with a piece of gauze 
dipped in a saturated boric acid solution, care being taken not to injure 
the delicate buccal mucous membrane. During the first two weeks 
of life the mouth should be cleansed just before each nursing. This is 
of advantage to both mother and babe, as during this period the 
nipples of the mother and mouth of the child are especially liable to 
become the seat of disease. 

Rash. — The skin of the newborn babe is easily irritated, and causes 
quite incapable of doing any harm in older children may produce 
erythema, eczema, or intertrigo in infants, especially in the folds of 
the groins and genital region. Perfect cleanliness, the use of castile 
instead of irritating soaps, keeping the folds dry, and using a dusting 
powder of starch, lycopodium, or zinc oxide, will usually be found all 
that is necessary to prevent the development of these annoying 
conditions. 

Genitals. — The genitals should be kept clean, but not washed of tener 
than the rest of the body, unless soiled by vaginal or rectal discharges. 
In boys the prepuce should be examined and retracted daily, if tight 
or long, until the parts are in a normal condition. Circumcision is 
often necessary. It usually removes more or less local irritation. It 
may do much good — if properly performed it can never do harm. 

It is important that the child should be taught to exercise control 
of the bladder and rectum quite early in life. When six months 
old the child should be placed in its chair for about three minutes or 
less, preferably just after each feeding. If this rule is adhered to 
systematically the majority of children will, at the age of one year, 
have learned to control the discharge of both urine and feces. This 
is of advantage to the child, as the evacuation of the bladder and 
bowel at certain regular intervals is important, and the training of 
the child itself is also of benefit. 

Anal Region. — During the first year of life and often until the end 
of the second year, if the child has not been so trained, the nurse is 
compelled each day to devote considerable time to the washing of the 



CARE OF THE NEWBORN 27 

napkins, and such time is perhaps taken from the hours which the child 
should spend in the open air. The nurse, if relieved of this washing, 
is also, in my experience, much more cheerful and manageable. Again, 

it is certainly not hygienic for a child to be wearing articles of clothing 
soiled by urinary or fecal discharges any longer than is necessary. 

Vaccination. — All children should be vaccinated during the first 
year of life; after the third month is preferable; and better, if possible, 
during the cool than the hot months. If the arm is properly protected 
from infection by an appropriate dressing the symptoms produced by 
vaccination are slight and temporary. Vaccination should be deferred 
in a child who is frail, ill, or suffering from any skin disease. 



CHATTER II. 
NORMAL DEVELOPMENT OF THE CHILD. 

As a rule, it may be stated that for a child to develop according to 
normal standards, certain conditions such as heredity, environment, 
birth, food, and hygienic surroundings, should be up to the normal or 
usual standards. Ideal conditions are unnecessary, but the better the 
conditions are the greater is the probability that the infant will develop 
properly. 

Normal development differs greatly in races and in the same race 
under different environment. In the monkey tribe it requires from 
six to ten years to reach full intellectual and physical development. 
In certain African races the span of life is only thirty years, and the 
children of these savages are ver} T precocious. They walk very early, 
and reach puberty and full intellectual development at the age of ten 
years. 

Caucasian infants of civilized countries are the least precocious 
of all races, requiring twenty-five years to attain full mental develop- 
ment; and, as the developmental period is the most important one in 
the life of the individual, it follows naturally that we cannot be too 
careful that the individual lives during this period under conditions 
which will best promote his mental and physical progress. 

There are certain portions of the body that develop rapidly in size, 
but acquire their complete functional activity slowly. A striking 
example of this is seen in the infant twelve months old, whose brain 
is almost two-thirds as large as the adult's, but the functions of this 
brain require years of careful training for their development. It is 
well for us to appreciate that normal children come from normal 
parents, and that much can be accomplished by a better physical, 
mental, and moral training of the masses. If the physical nature alone 
is developed we produce a race of athletes. If the mentality only is 
cultivated we develop a people among whom prodigies and precocious 
youths are the rule rather than the exception. If only the moral side 
is developed the race becomes narrow-minded and fanatic. 

How many children are systematically weighed and measured to 
see if they are growing and developing normally? and how much time 
do parents, as a rule, give to the study of their child's growth and 
development? Normal development is more likely to be found where 
systematic medical examinations of the child are made. This is now 
becoming the rule among the better educated, and school physicians 
are of much assistance in detecting both acute and chronic conditions 
among those who are, perhaps, less often taken to a physician. All 
children who are compelled to work should be pronounced by a 



NORMAL DEVELOPMENT OF THE CHILD 29 

physician to be fit and capable of working before being employed, 
and the law concerning age limit and hours of employment should be 
strictly enforced. 

During school life many factors combine to retard the normal 
growth of children, both boys and girls. The daily sessions are too 
long, and the concentration of attention demanded by lengthy recita- 
tions is also too great a tax. Kecesses do not come frequently enough 
to relieve the inactivity and tension of the child's muscles. Oppor- 
tunities to relieve the bladder and rectum are most important, and 
should be provided for. Sometimes, through timidity, the child will 
fail to obey such calls until reduced to an agony of nervousness. There 
are also too many hours of home study; the child needs most of these 
hours for play or family association; and during her hours out of 
school the little girl should not be taxed with sewing, knitting, painting, 
or too many piano lessons. The free hours would be far better occupied 
in winter by gymnastics or skating, and in summer by swimming or 
cycling. 

During the long summer vacation the child should not be obliged 
to carry out a course of study prescribed by the school before closing, 
such as the reading of certain stipulated books, the writing of compo- 
sitions, etc. As a rule, school teachers fully appreciate the importance 
of hygienic measures, but cannot personally apply these principles to 
the welfare of the pupils. In the early morning hours the mind is most 
alert to permanent impressions, the muscles most capable of doing 
their hardest tasks. After the first fatigue drop at noonday the blood 
tension and temperature increase steadily until their highest point 
at 6 p.m. From this time on the natural craving of adult or child is 
for rest and sleep. Sleep is necessary; even the young mammal toward 
evening will suckle or eat, then play, and settle itself to sleep. 

High blood-pressure we know precludes sleep; yet in this period the 
plastic body of the child often suffers lasting injury by being driven 
to evening study. Thus we defeat the very purpose toward which all 
education is directed — namely, the production of the highest degree 
of efficiency. The system of cramming for examinations, which so 
closely follow each other as to be no gauge of the child's advancement, 
is another pernicious factor that adds to the general high tension. 
The fact seems to be often overlooked that there is an education higher 
and far better calculated to fit the child for life than the mere imparting 
of a mass of facts. The inculcation of moral principles, which the 
child may have no opportunity of learning elsewhere, forms a much 
more stable foundation. 

The physical conditions upon which the activity of the mind depends 
are very complex, and it certainly seems only reasonable to believe 
that, during the years in which the bodily growth is most rapid, 
there should be a corresponding reduction in the amount of mental 
and physical work imposed upon the child. This is necessary even 
if the child is apparently perfectly able mentally and physically to do 
the work. 



30 NORMAL DEVELOPMENT OF THE CHILD 

It is an interesting fact that bright boys are, as a rule, taller and 
heavier than dull boys, and it is also well established that, as the age 
increases, brilliancy in most studies decreases, and that the ability to 
learn and absorb quickly is an attribute of the young. Normal children 
should be studied more, and the normal standard is best ascertained 
by the careful study of the physical statistics of a large number of 
children. These are often of great value, and frequently furnish 
important information both to the physician and educator. Special 
attention is necessary during the two years before puberty, as in both 
boys and girls this is the period of most rapid growth in both height 
and weight, the age being from twelve to fourteen years for girls and 
from fourteen to sixteen for boys. 

Height. — Heredity is a distinct factor in height, the children of 
tall parents being, as a rule, taller than those of short parents. 
Rachitic children are, as a rule, shorter than those of the same age 
who are not rachitic. It is also of interest to note that often during 
acute febrile conditions the child may show a rapid growth in length, 
notwithstanding a decided loss in weight, malnutrition evidently 
affecting the weight but not the height. Children grow most rapidly 
during the first year, and especially during the first three months of 
life. The average length of boys at birth is 19f inches (49.5 cm.), 
and of girls slightly less, 19J inches (48 cm.). During the first two 
years the growth is about the same for both girls and boys. From the 
third to the twelfth year girls grow more slowly than boys. After the 
twelfth year, owing to the earlier advent of puberty, the girl grows 
more rapidly and overtakes the gain made by the boy. The boy 
develops the more rapidly from the fourteenth to the sixteenth year, 
and again passes the girl in height. 

The growth of the child during the first year is 8 inches (20 cm.), 
in the second year 4 inches (10 cm.), in the third year 3.2 inches (8 cm.), 
in the fourth year 2.8 inches (7 cm.), from the fifth to the eleventh 
year the child grows from 2 to 2| inches (5 to 6 cm.) each year, and 
at the age of puberty both girls and boys grow from 2 to 3 inches 
(5 to 7.5 cm.) each year for two or three years. 

During the day the child decreases in height and gains in weight, 
during the night he increases in height and loses in weight. 

At the age of five years the child is twice as tall as at birth, and at 
fourteen years three times as tall as at birth. 

Insufficient food and poor hygienic surroundings usually retard both 
growth in height and weight; whereas acute illness often results in a 
growth in height, notwithstanding a loss in weight. 

Weight. — A delicate, premature, or undersized infant should be 
weighed every day; infants of normal weight at birth should be weighed 
twice a week during the first six months, during the second six months 
once a week, during the second year every two weeks, and a careful 
record should be kept of these weighings. It is necessary to appreciate 
that a gain in weight does not always signify an improvement in 
the general, physical, and nervous condition. The tissues may be soft 



WEI CUT 31 

and flabby, the bones rachitic, the child anemic and neurotic, and yet 
the scales indicating a gain in weight might divert one's attention from 
these conditions, unless care is taken to note that a gain in weight to 
be satisfactory must go hand in hand with normal development in 
every other respect. 

If fed on high percentages of starches and sugars, they may gain 
in weight but the tissues are apt to be soft and flabby. The importance 
of a failure to gain in weight is evident. It signifies either that the 
different food elements are deficient in quantity or quality properly 
to nourish the infant, or that all or one of them is not adapted to the 
child's digestive powers; again, the child may be digesting its food 
properly, but some other condition, such as fever or loss of sleep, may 
be so increasing the metabolic processes that no gain in weight results. 

In other cases the quantity and quality of the food offered may be 
correct, but the infant fails to take a sufficient amount. Bottle-fed 
babies are much more likely to develop gastro-intestinal disturbances 
than those who are breast-fed, and the problem of a child with station- 
ary or decreasing weight must be studied from the stand-point of that 
individual child, and the different causes, such as food, the personal 
and family history, hygienic surroundings, gastro-intestinal or other 
diseases considered. The weight curve of the bottle-fed baby is usually 
below that of the breast-fed infant, and irregularities in this curve are 
more frequent. 

In order to avoid errors in the weight chart a child should always be 
weighed in the same clothes, the fewer the better, on the same scales and 
at the same time of day. The lightest weight is usually reached by the 
third day, the loss in weight during the first three days being accounted 
for largely by the small amount of breast milk received by the infant 
and the loss of meconium and urine. During these first few days water 
should be given freely, and while it is not wise during this period, either 
from the stand-point of the child or the mother, to force it to nurse too 
frequently, still it is a well-established fact that the sooner the child 
begins to receive an abundant supply of breast milk the sooner does 
this initial loss of weight cease. 

The presence of the colostrum corpuscles is also an element in the 
weight loss, as the loss of weight is largest when the colostrum 
corpuscles persist. The average loss during these first three days is 
about six to eight ounces, and this should all be regained by the end 
of the first week. If, after the third day, the weight still continues to 
fall, or even remains stationary, it points to either a deficient secretion 
of breast milk or, perhaps, some abnormal condition in the infant of an 
inherited or acquired character — among the former syphilis or some 
congenital malformation, among the latter sepsis and gastro-intestinal 
or pulmonary disease. Such a child must be studied most carefully 
in order as early as possible to correct or at least modify the cause of 
its failure to gain. This is of importance, as an unnatural loss of weight 
during the first few days or weeks of life is often regained very slowly 
and with difficulty. 



32 



NORMAL DEVELOPMENT OF THE CHILD 



The normal increase in weight in the child during the first year is 
remarkable. It should double its birth weight when five months old, 
and treble it at one year. The infant starting with a small initial birth 
weight has less vitality than the heavier baby, the rule being that 
the greater the weight the greater the vitality. Ordinarily the baby 
small at birth will present during its first year a weight chart with 
a lower curve than the one shown by the infant heavier at birth. To 
this rule there are, however, many exceptions, as it is quite common to 
find the child small at birth, if normal and healthy, gaining so rapidly 
in weight that at five months and one year its weight is equal to the 
normal weight of the infant heavier at birth. The accompanying 
chart (Fig. 1) shows the usual weight curve during the first two 
year in a child of average birth weight. 



MONTHS OF AGE 


1 


2 


3 


4 


5 


• 1 1 


8 


9 


10 11 


12 | 1 


4 161 


8 202 


2 24 


WEEKS OF AGE 


2 4 


6 8 


10 12 


14 16 


18 20 


|22 24 20 28 


30 32 34 


36 38 


40 42 44 46 


48 50 52 














GRMS. 
1316b 
127 1 2 
12256 
1 I804 
1 1350 
10890 

9980 
9530 
9070 
8620 
8160 
7710 
72P0 
68U0 

5900 
5440 

4540 
4080 
3630 
3ieo 
2720 
2270 
1816 


LBS. 
29 
28 
27 
2C 
25 
24 
23 

21 
20 

19 

17 

15 

13 

12 

9 

8 

7 

5 

4 


















































































































































































































































_|_ 






























































































































it 






























































































































i 






























































































































±1 




























































































































































































































































' 




























































































































S 
































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































■" 




















































































































































































































































































































































































































































































































































































































































































































































































































































1 



































































































































































Fig. 1.— Weight chart. 



This, of course, represents only the average weight. There is, 
however, a distinct tendency for both the light and heavy infant 
at birth to conform closely to this curve, provided the child is normal 
and healthy. This rapid gain in weight, in conjunction with the 
great amount of heat lost by the infant's body, necessitates an amount 
of food which is proportionately large for the child's age, especially 
when one considers the excessive metabolism of the growing baby. 
The production of heat required by an infant is much greater in 
proportion than that required by the adult, because the infant has 
a smaller body but a greater skin surface relatively than the adult. 
If this heat is not produced, the body temperature of course cannot 
be maintained. 

The weight gained during the second year is six pounds, the third 
year four and one-half pounds, the fourth year three and one-half 
pounds, from the fourth to the eighth year four pounds each year, 
and from the eighth to the eleventh year six pounds each year. 

The following tables give the average height and weight of both 
boys and girls from birth to sixteen years: 



WEIGHT 



33 



HEIGHT. 
Age. Boys. 

Birth 19% inches 

1 year 28^ " 

2 years 32^ " 

3 " 35 

4 " 38 

5 " 41 

6 " 43^ " 

7 " 45H " 

8 ." 47^ " 

9 " 49}^ " 

10 " b\y 2 " 

11 " 53H " 

12 " 55 

13 " 58 

14 " 60 

15 " 63 

16 " 65 



Girls. 

19% inches 
28 

3214 - 

34^ " 

37% " 

*oy 2 - 

43% " 

45% " 
47 

49% » 

513^ " 

53^ " 

553^ " 

58% - 
60 

61^ - 
62 











WEIGHT. 


Age. Boys. 


Birth .... 7 pounds 8 ounces 


5 months 






15 


1 year 






21 


2 years 






27 


3 " . 






32 


4 " 








37 


5 " 








41 


6 " 








45 


7 " 








49 


8 " 








54 


9 " 








60 


10 " 








66 


11 " 








72 


12 " 








79 " 12 ounces 


13 " 








88 " 


14 " 








97 


15 " 








108 


16 " 








119 



Girls. 
7 pounds 2 ounces 
14 " 4 " 

20 " 6 " 

26 

31 

36 " 4 u 

40 

44 

48 

52 '• 8 " 

58 " S " 

64 

70 " 4 " 

80 

90 
100 
108 
113 



The child who is increasing normally in weight is twice as heavy at 
the age of six years as it was at one year, and at the age of thirteen 
years has doubled the weight of six years. 

The failure of an infant to gain in weight is often the first indication 
to the physician that the child is not developing normally, and should 
be a sufficient reason for making a careful examination of the infant's 
food and life; if the examination is successful the cause of this failure 
to gain will be discovered, perhaps long before any evidence of de- 
ficiency in the quantity or quality of the food, or any signs or symptoms 
of indigestion or other illness have become sufficiently marked to 
attract attention. In fact, it is impossible for any one to decide 
except by the use of the scales just what progress the baby is making, 
and the failure to weigh the baby systematically often accounts for 
nutritional disorders being unnoticed and not treated sufficiently 
early. 

With the possible exception of the first two years of life, the growth 
which occurs at puberty is the most important. It is the time of the 
3 



34 NORMAL DEVELOPMENT OF THE CHILD 

most rapid growth and development of the entire body, of the greatest 
increase in both height and weight, and at this period we find also the 
most rapid development in chest measurements, in lung capacity, 
and in the muscles of the arms and legs. 

The custom of putting children to work, especially in ill-ventilated 
apartments, during this critical period cannot be too strongly con- 
demned, as such children invariably show subnormal development. 
Statistics carefully collected on a large scale in England prove that in 
children who work half time in the mills subnormal development is as 
follows: At the age of eleven years, 7.5 per cent.; twelve years, 11.2 
per cent.; thirteen years, 15.7 per cent.; fourteen years, 19 per cent.; 
fifteen years, 26.5 per cent. Could anyone wish a more striking example 
of the injurious effects of child labor? 

Head. — At birth, especially if labor has been difficult or prolonged, 
the infant's head is often elongated in its anteroposterior diameter. 
This condition, the result of pressure during labor, is usually of no 
pathological significance, and, as a rule, disappears in the course of a 
few weeks. The larger the child the larger should be the head; and, 
while a certain amount of variation from the normal may be of no 
special importance, still an infant's head considerably above the 
normal size should at least suggest the possibility of hydrocephalus, 
rickets, or possibly cretinism. 

If the infant is much below normal weight its head will, of course, be 
smaller than normal, and this is the case in premature infants, al- 
though in premature infants the head is large in proportion to the 
thorax. A head much smaller than normal in a well-developed baby 
at full term should suggest microcephalus, and possibly mental 
deficiency. In deciding as to the probability of the head being of 
normal size, it must be borne in mind that the maximum circumference 
of the head and of the thorax during the first two years of life 
correspond very closely. After this period the chest increases more 
rapidly in size, as is shown by the following table: 

Circumference of head 

At birth 13 . 5 inches 

6 months 17 . 

lyear 18.0 

18 months 18.5 

2 years 19.0 

5 " 20.5 

10 " 21.0 

15 " 22.0 

The anterior fontanelle always exists at birth, and may vary in size 
from one-half to two inches laterally, and from two to three inches 
longitudinally. It changes very little in its diameters until the ninth 
month, when it gradually begins to unite, and is usually entirely 
closed by the eighteenth month. If the child is robust, and the head of 
normal size, the early closure of the fontanelle usually is of no signifi- 
cance. The failure of the suture to close until a few months later 



Circumference of tr 


12.5 inches 


16.5 " 


18.5 " 


19.0 " 


19.5 " 


21.5 " 


25.0 " 


30.0 " 



THYMUS GLAND 35 

than normal may simply indicate malnutrition; but, if the head is 
unnaturally large, may point to rickets, hydrocephalus, or cretinism. 

Owing to the lack of ossification the bones of the skull in the infant 
are very soft and the skull may even become' misshapen by allowing 
the infant to lie continually on one side. 

The principal sutures of the head are, as a rule, ossified at the 
seventh month, although a delay of one or two months is of no 
special significance. 

Neck. — A casual examination gives one the impression that the neck 
of the infant is short. In reality the cervical portion of the bony spine 
is longer proportionately than in the adult. The apparent shortness 
is due to the high position of the sternum, the large deposit of super- 
ficial fat in this region in the infant, and the failure of the young child 
to hold its head erect. 

Spine. — In the young infant the spinal column presents the sacral 
curve and a long posterior curvature or convexity extending above 
the sacrum. The normal spinal curves develop as age advances, the 
curve in the cervical region appearing when the baby is able to hold its 
head erect, and the curves in the lumbar and dorsal spine developing 
when the child is able to walk. The spinal cord descends to the third 
lumbar vertebra in the young infant, a point lower by one vertebra 
than its lowest point in the adult. 

The spine in the infant and young child, owing to the large amount 
of cartilage and comparatively small amount of bone cells, is very 
flexible, and can therefore bend or be bent to a degree much greater 
than is possible in the adult. Its greater flexibility and lack of ossi- 
fication render it more susceptible to slight and temporary influences 
of an injurious nature than is the case with the adult bony spine, and 
predispose the infant and young child to spinal deformities. A line 
drawn between the anterosuperior spinous processes of the ilia passes 
over the spine of the fourth lumbar vertebra, and is a useful landmark 
in lumbar puncture. 

Thymus Gland. — The thymus develops during fetal life from the 
third visceral pouches on either side, and thus forms a bilaterally 
symmetrical tubular organ stretching out between the thyroid and 
upper limits of the heart. The epithelial elements are more and more 
encroached upon by surrounding vascular and lymphatic tissue, 
so that at birth the gland consists largely of the latter, containing 
only epithelial remnants in the form of so-called Hassal's corpuscles. 
The thymus gland grows up to the second or third year of life, when its 
weight varies between 7 and 27 grams (0.2 and 0.9 of an ounce); 
Friedleben gives it at 27 grams as compared with 14 grams (0.5 of an 
ounce) at birth. Atrophy of the thymus begins after the second or 
third year and progresses slowly until puberty. From puberty to 
early adult life the atrophy progresses rapidly, and at adult life very 
little thymus tissue remains. 

The thymus consists usually of two flat slender lobes joined in the 
middle by delicate connective tissue. It moves up and down with 



36 NORMAL DEVELOPMENT OF THE CHILD 

respiration. At birth it is of a faintly red color, moderately soft, 
and loosely enclosed in a thin capsule which in its turn is closely 
connected with the surrounding structures, the trachea, the arch of 
the aorta, the pulmonary artery, the superior vena cava, both in- 
nominate veins, the recurrent and pneumogastric nerves, also the 
upper part of the epicardium and the apices of the lungs. The gland 
usually reaches up into the episternal notch, but not necessarily so, 
even when enlarged. Its close proximity to so many important organs, 
and the fact that the distance between the manubrium and the verte- 
bral column in infants is little more than 2 cm., accounts for the very 
serious disturbance which may arise from an abnormal enlargement 
of the thymus. 

The thymus is a ductless gland supplied by the vagus and sym- 
pathetic nerves. Researches as to its function are not yet conclusive. 
During the last fetal months it plays a part in the making of blood. 
It is claimed also that it has an internal secretion similar to that of 
the thyroid which influences the general growth and development 
of bones, and perhaps also the blood-pressure. Complete extirpation 
of the gland in dogs has resulted in osteoporosis, osteomalacia, and 
rachitis, possibly as a result of acid intoxication which has interfered 
with a deposit of lime salts in the bones or has dissolved some already 
deposited. 

The condition of the thymus gland seems also to be an index of the 
general condition in infants, as in 18 cases of marasmus the average 
weight of the gland was found at autopsy to be only 2.2 grams (33.9 
grains) as against 18 grams (three-fifths of an ounce) in the normal. 
As a possible explanation of idiotica thymica, it seems interesting that 
Bourneville at postmortem found the gland absent in 25 out of 28 
mentally weak children. 

Thorax. — The chest of the child is barrel-shaped and gradually 
changes to a dome-shape at puberty. The anteroposterior and trans- 
verse diameters are nearly equal at birth, but after the third year 
the transverse increases more rapidly up to puberty than the antero- 
posterior. The lungs, on account of the shape of the chest, lie more 
posteriorly than in the adult. The walls are very elastic, as the spine, 
ribs, and sternum are largely cartilaginous. The chest walls are also 
thinner, owing to their slight muscular development; and in normal 
infants the superficial tissues are composed largely of fat. The high 
position of the diaphragm, the large thymus, and possibly dilated 
stomach and bowels tend to lessen the size of the thorax. 

In newborn infants the maximum circumference of the chest is 
about three-fourths to one inch less than the maximum circumference 
of the head; at six months it is one-half inch less than the head; 
but at one year the thorax not only equals the head in size, but 
its maximum circumference is now one-half inch greater than the 
head. During the first three years the difference in the size of the head 
and thorax is very slight, a fact which is often of assistance in suspected 
microcephalic or hydrocephalic conditions. A very fat child will, of 



FETAL CIRCULATION ?>7 

course, have a large chest; on the other hand a small thorax should 
always be looked upon as an indication of imperfect development, 
and should suggest the necessity for regulated calisthenics. Rickets, 
empyema, emphysema, cardiac disease, and, in older children, Pott's 
disease or lateral spinal curvature, cause more or less thoracic deform- 
ity. "Trichter-brust" is a funnel-shaped depression at the lower end 
of the sternum. It may be congenital or the result of rickets; in the 
former case the lower end of the sternum is very much retracted; in 
the latter other evidences of rickets are usually present. 

If after the second year the chest is smaller than the head, it may 
indicate that the head is enlarged as in rickets or hydrocephalus, or 
the unnatural smallness of the chest may be the result of disease of 
the lungs or of some interference with respiration, such as may be 
produced by adenoids. A long, narrow, and flat chest suggests the 
tubercular type, while a pigeon-shaped breast points to rachitis, 
an asymmetrical chest suggests pleural effusion, pneumothorax, or 
scoliosis, while precordial bulging may indicate heart disease. 

From birth until the seventh year the most noticeable change in the 
thorax is the increase in its tranverse diameter; during these years 
the chest also greatly increases in its vertical length, while from the 
sixth to the ninth year the vertical diameter develops more rapidly 
than the transverse. At puberty there is again a rapid increase in the 
vertical diameter, especially in boys. The infant's shoulders are small 
and the ribs more nearly horizontal than in the adult. By the end of 
the second year the sternum has a number of centers of ossification, 
but is still largely cartilage; the manubrium and gladiolus are fairly 
well ossified, while the ensiform cartilage ossifies more slowly. 

Fetal Circulation. — The circulation in utero is carried on without 
any oxygenation of the blood by the lungs of the fetus. The oxy- 
genated blood from the placenta, carried by the umbilical vein, enters 
the fetus at the umbilicus, and then passes to the under surface of the 
liver of the fetus where it gives oft' two or three branches to the left 
lobe. Farther on, at the transverse fissure, it divides into two branches, 
the larger of these joining the portal vein and entering the right lobe; 
the smaller, the ductus venosus, joining the left hepatic vein at the 
point where the latter empties into the inferior vena cava. All the 
blood entering the fetus by the umbilical vein except that portion which 
passes through the ductus venosus traverses the liver, and empties 
by the hepatic veins into the inferior vena cava. 

The inferior vena cava, which contains also the blood deoxidized by 
its passage through the lower extremities, empties into the right 
auricle, and, guided by the Eustachian valve, passes through the 
foramen ovale into the left auricle. Here it mixes with the small 
quantity of blood which, having served to nourish the lungs, is emptied 
by the pulmonary veins into the left auricle. The blood passes from 
the left auricle through the mitral orifice to the left ventricle, and from 
the left ventricle through the aortic valves into the aorta, and is in 
large part conveyed by the carotid and subclavian arteries to the head 



38 NORMAL DEVELOPMENT OF THE CHILD 

and upper extremities which, thus receiving (he major portion of the 
oxygenated blood, are especially well-developed at birth. A small 
portion of this blood, however, passes into the descending aorta. 

The blood from the head and upper extremities is returned by the 
veins to the superior vena cava and into the right auricle, where it 
mixes with a small portion of the blood emptied into the right auricle 
by the inferior vena cava, the major portion of this latter blood having 
passed directly through the foramen ovale into the left auricle. The 
small portion of blood from the inferior vena cava that does not pass 
through the foramen ovale, mixing with the blood that enters the right 
auricle by the superior vena cava, passes through the tricuspid orifice 
into the right ventricle, and from the right ventricle into the pulmonary 
artery. 

As the lungs require only a small portion of blood to nourish them, 
the amount distributed to them by the right and left pulmonary arteries 
is not large, and, after performing its function of nourishing the lungs, 
it empties into the left auricle by the pulmonary veins. The major 
portion of the blood entering the pulmonary artery passes through the 
ductus arteriosus into the descending aorta, mixing with the small 
quantity of blood which passes into the aoijta from the left ventricle. 
This blood containing a small proportion of oxygen passes down 
and supplies the viscera of the abdomen and pelvis and the lower 
extremities, the major portion of it, however, being conveyed by the 
umbilical arteries to the placenta, where it is again oxygenated. The 
small portion of blood passing to the lower extremities explains their 
comparatively small size and lack of development at birth. 

The important points which one should remember in the infant 
and fetal heart are: (1) the opening between the two auricles, and 
(2) in connection with this opening the large size of the Eustachian 
valve. Situated as it is on the left side of the opening of the inferior 
vena cava, it serves to guide the blood through the foramen ovale from 
the right into the left auricle. 

The heart of the newborn occupies a vertical position until the 
fourth month. After this period it gradually assumes an oblique 
position. Its size as compared with the body is at birth as 1 to 120, 
at the second month as 1 to 50, and in adult life as 1 to 160. Early 
in fetal life the auricles are larger than the ventricles, the right auricle 
being larger than the left. Near the end, however, of intra-uterine life, 
the ventricular portion becomes the larger, the left ventricle as the 
period of birth approaches becoming thicker than the right. 

As soon as the child breathes, an increased amount of blood from the 
pulmonary artery passes into and through the lungs, and they at once 
assume the function of oxygenating the infant's blood. 

After the fifth month of intra-uterine life, the lumen of the ductus 
arteriosus gradually decreases, and its rapid obliteration as a blood- 
vessel is therefore quickly accomplished after birth. At birth only a 
small portion of blood passes through the ductus arteriosus, and its 
lumen, already considerably lessened, quickly becomes obliterated, 



RESPIRATION 39 

no blood passing - through it after the sixth to the tenth day. The 
foramen ovale rapidly closes and becomes practically impervious to 
the passage of blood at about the tenth day after birth. A small 
slit-like opening, however, usually persists for some months; in 
fact, some weeks before birth the foramen ovale gradually becomes 
smaller as the result of a septum which is slowly closing the orifice. 
With the ligation of the cord the blood ceases to flow through the 
umbilical arteries, clots form in each artery, and, becoming organized, 
result in the closure of their lumina. The umbilical vein is also obliter- 
ated, having become the round ligament of the liver. The time required 
to complete the circulation in the infant is at birth twelve seconds, 
at five years of age fifteen seconds, at fourteen years eighteen seconds; 
in the adult it is twenty-two seconds. 

Pulse. — The frequency of the heart's action is shown in the following 
table : 

Pulse. 

Before birth 150 

At birth 130 to 140 

First year 115 to 130 

Second year 100 to 115 

Third year 90 to 100 

Fourth to seventh year 86 to 90 

Seventh to fourteenth year 80 to 85 

The pulse, if possible, should always be taken when the infant is 
very quiet, or, better, if asleep. Under perfectly normal conditions 
its rate varies much more than in the adult, and the slightest movement 
will increase the rapidity of the heart's beat; the more violent the 
movement or excitement the greater will be the increase. An increase 
of from twenty to thirty beats in the minute may easily follow any 
excitement or unusual exertion, the slightest cause being enough 
to disturb the rate and force. The rapidity of the pulse is of less 
significance than its force. An infant ill from any cause may have a 
pulse of 150 to 175 or even higher and be in no danger, while the same 
pulse rate if lacking in force would be of much more serious conse- 
quence. The pulse wave of a healthy infant shows dicrotism, which 
becomes more marked in cardiac disease and in all acute infectious 
diseases. 

Respiration. — Respiration is more rapid in infancy and early life 
than in the adult, although it tends to approach the adult type earlier 
than does the pulse. The rhythm during infancy varies greatly, even 
in the perfectly normal and healthy baby. Respiration in the infant 
is of the abdominal type, the muscles of the chest being poorly 
developed, while the muscles of the abdomen and diaphragm are 
well developed. The abdominal or diaphragmatic type of respiration 
persists until about the tenth year in girls and the eleventh year in 
boys, when it gradually tends to change to the costal type. In the 
infant respiration may for a few moments be quite superficial, perhaps 
changing a few seconds later and becoming deep. The period between 
inspiration and expiration also often varies. While a disturbance of the 



40 NORMAL DEVELOPMENT OF THE CHILD 

respiratory rhythm is of no significance in infants, and, in fact, occurs 
regularly in the normal infant, it is of importance to appreciate that 
this is a phenomenon of infancy only. In the child of two years or 
older a disturbance of the rhythm or the rapidity of respiration often 
suggests the possibility of brain or lung disease. Comparatively slight 
causes — a moderate fever, excitement, violent crying, or slight muscular 
exertion — will in the infant cause not only a change in the rhythm 
but also a marked increase in the respiratory rate. 
The frequency of the respiration is shown in the following table: 

At birth 35 to 50 per minute 

At first year 28 " 

At 2 years 25 

At 5 " 22 

At 10 " 18 

Temperature. — The temperature of an infant or small child should 
always be taken in the rectum; the temperature so taken is more 
reliable than that in the axilla or groin, and, owing to the liability of 
breakage, the method is safer than when taken in the mouth. The heat 
centre in the young is evidently not fully developed, and slight causes 
easily disturb the equilibrium of the temperature. It is almost in- 
variably higher in infants than it would be in adults, the two suffering 
from the same disease. Infants produce more calories in proportion 
to the body weight than adults, but give off more heat in proportion 
to their size. They are, therefore, less able than adults to stand 
extreme cold. 

The temperature of the infant falls from 1.5° to 2° during and 
after the first bath, and requires from twelve to twenty-four hours to 
return to the birth temperature. In weak or premature infants the 
fall may exceed 1.5° to 2°, and the temperature may with difficulty 
return to the original temperature at birth. This, of course, is a strong 
argument for the omission of the bath in such children, and, in addition, 
usually indicates the necessity for the employment of external heat. 

Slight variations in the temperature invariably occur even in 
normally developed and healthy infants, and, if not exceeding 0.5° F., 
are of no significance. The bottle-fed baby ordinarily shows a more 
irregular temperature than the infant raised at the breast. During 
sleep the thermometer often registers from 0.2 to 0.5 of a degreee less 
than when the infant is awake and active. Very slight causes or mild 
illness will often produce in the infant or young child an elevation 
of from 1° to 3°. Excitement, unusual exertion, crying, or too many 
clothes on infants in hot weather will often cause a similar rise. 

If the temperature remains continuously high it usually indicates 
some serious illness. .An intermittent temperature may or may not 
be associated with illness of much consequence. It is extremely 
important, however, to appreciate that, while variations in temperature 
in the infant may be and "often are produced by slight causes, one must 
not go to the other extreme, and become careless as to the danger which 
may be associated with such changes. 



MUSCULAR DEVELOPMENT 41 

Fever may occur as a part of many of the illnesses from which an 
infant or young child is suffering, and yet the symptoms of this illness 
may be vague and uncertain. The fever occurring in measles previous 
to the appearance of the rash, the temperature during the first few days 
of typhoid, and the fever associated with otitis media may be of great 
significance, and yet the symptoms be, possibly, very obscure. The 
broad rule of never making a diagnosis until the child has been. care- 
fully examined from head to foot, not forgetting the throat and skin, 
is often the only means of deciding as to the significance of a fever. 

Subnormal temperatures are sometimes the result of allowing the 
thermometer to remain too short a time in position, or from being 
taken in a moist axilla. In premature or delicate infants also the tem- 
perature is often below the normal, and in cases of marked malnutrition 
subnormal temperatures are the rule and not the exception. The 
temperature is often subnormal in children with congenital and 
acquired heart disease. In older children a subnormal temperature 
is associated with a number of pathologic conditions, of which may 
be mentioned diabetes insipidus and mellitus, Addison's disease, and 
myxedema. 

It is an interesting fact that in many cities the maximum outdoor 
temperature occurs at 2 to 3 p.m., and that the maximum temperature 
in dwellings, that is, indoors, is almost always at its height at a con- 
siderable number of hours after 2 to 3 p.m., perhaps at 8 p.m., or, 
possibly, well into the night or early next morning (3 a.m.). Observa- 
tions taken on a large scale in poorly ventilated and small apartments 
show that under such conditions the maximum temperature indoors 
very often occurs late in the evening or late in the night. Children 
sleeping in such rooms should, of course, never be bundled up even if 
the night air outside is cool. 

Muscular Development. — While the muscles of the infant are fairly 
well-developed, coordination does not exist. Glycogen is present 
in the muscles in small amounts, about 0.5 of 1 per cent.; there is also 
a small amount of grape sugar. The electrical response to both 
galvanism and faradism is diminished at birth, and the response to 
electrical stimulation is more slowly elicited, the period of latency being 
longer. Motion is, to a degree at least, reflex, and is more or less 
associated with a sense of feeling or touch. 

During birth the only muscle liable to injury is the sternocleido- 
mastoid. In breech presentations a blood clot with, perhaps, a tearing 
of some of the muscle fibers may take place. A swelling the size of a 
robin's egg ma}' be noticed, usually on the anterior aspect of the muscle; 
it is, as a rule, absorbed spontaneously in the course of a few weeks, 
although shortening of the muscle and torticollis may follow. 

The hands at birth seem to show considerable muscular develop- 
ment, as illustrated by the strong grasp of the newborn infant. At 
three months the infant will hold its head erect fairly well, and at the 
age of six to seven months it can be placed on a large firm mattress 
or on a blanket on the floor, or, still better, in a pen, and left to learn 



42 NORMAL DEVELOPMENT OF THE CHILD 

to creep. At eight or nine months old, if normally developed, it will 
have acquired the power to move its body from one place to another, 
either by rolling, pushing, or creeping. An infant should always lie 
on a firm mattress, and often be placed on its abdomen as well as on its 
back, and invariably be loosely dressed so as to allow free movements 
of its neck, arms, body, and legs. 

At the age of ten months a child usually begins to grasp a chair or 
the side of its crib or pen, and to draw itself up on its knees. At the 
age of twelve months it should be able to walk with assistance. Failure 
to walk at twelve or thirteen months may be due to timidity, poor 
bony and muscular development, or to mental deficiency. It must be 
remembered that it is wise to give the infant all possible freedom of 
movement and exercise, and to allow it voluntarily to creep, to stand, 
and to walk. Unusually large and heavy children often walk late; 
this may be more to their advantage than otherwise, as their bony 
and muscular systems are less firm and resistant than normal, hence 
less able to support the child in the upright position. 

After the ability is acquired to stand alone some children quickly 
learn to walk alone; others, if timid or not very robust, may not 
walk alone for several months after the period of walking with assist- 
ance. In my opinion it is rarely necessary or advisable to encourage 
or to teach a child to walk. A child normal, physically and mentally, 
will naturally walk as soon as it is able to do so; in fact, the tendency 
should be more to restrain the child than to urge it on. 

Inability to grasp objects firmly in the hand at birth, to reach out 
for objects at the fourth or fifth month, to hold its head up at four or 
five months, to change its position at eight or nine months, to sit 
up at one year, or to stand at fifteen months, means usually that there 
is some physical or mental defect, and should at least make it impera- 
tive to examine most carefully into the mental as well as the physical 
condition of the child. 

According to Schlossmann, the infant in proportion to the weight of 
its body performs an amount of work about equal to that of an active 
adult, and the food required by an infant varies as does the food of an 
adult in direct proportion to the amount of muscular work performed. 

Nervous System. — Until the last few months of fetal life the cord 
extends to the end of the cervical canal. At birth, owing to the more 
rapid growth of the bony spine during the last few months of intra- 
uterine life as compared with the cord, the end of the clonus medullaris 
reaches to the third lumbar vertebra. In the adult the cord terminates 
at the lower end of the first lumbar vertebra. The average weight of 
the brain in the healthy newborn child is 12 to 13 ounces (350 to 370 
grams), and increases very rapidly, in the first nine months of life 
attaining one-third of its maximum weight, another third at about 
the age of two and a half years, and its final weight at about the 
twentieth year. The frontal lobes of the brain of the newborn are 
poorly developed, and the island of Reil is less distinctly outlined than 
later in life. Heredity affects especially the weight of the cerebrum. 



SPECIAL SENSES 4?> 

The cerebellum averages two-thirds of an ounce (20 grams) in weight 
at birth, and when fully developed about five ounces (140 grams). 
At the age of six months its weight increases to about two ounces 
(60 grams), and at two years to three and one-half ounces (100 grams). 
Its subsequent growth is much slower and its full development of 
five ounces (140 grams) is reached at about the same time as that of the 
cerebrum, 20 years. The weight of the boy's and man's brain is 
greater than that of the girl's and woman's brain at corresponding ages. 

The spinal cord of the newborn averages about one-tenth of an ounce 
(3 grams) in weight, and in the adult about nine-tenths of an ounce 
(27 grams). It weighs two-tenths of an ounce (0 grams) at five months, 
three-tenths of an ounce (9 grams) at one year, and four-tenths of an 
ounce (12 grams) at the age of two years. 

The excitability of motor nerves and muscles is very faint during 
the first two months, and the sensory nerves respond very slightly to 
electrical stimulation during this period, the face at birth being 
absolutely irresponsive to this stimulation. At birth the ganglion 
cells lack all the characteristic adult features, this being most marked 
in the cerebral hemispheres. Pigment is absent at birth and does not 
develop in certain portions of the nervous system until years afterward. 
At the age of one year brownish pigment is deposited in the locus 
cieruleus. The pigment of the vagus and substantia nigra begins to 
appear at the fourth year, and at the sixth pigment is found in the 
posterior spinal ganglia, but does not appear in the spinal cord until 
the seventh year. 

Many nerve fibers do not develop their myelin sheaths until after 
birth. This is most marked in the cerebral hemispheres; for while 
at birth the full proportion of myelin is present in the spinal cord, the 
cerebrum, cerebellum, medulla, pons, and quadrigeminal bodies pos- 
sess absolutely no myelin. 

In the fetus of eight months the tactile and muscle sense tracts are 
the only ones supplied with myelin sheaths. At full term the pyramidal 
tracts, the olfactory, the visual tracts, and the corona radiata possess 
more or less of their myelin sheaths. The lack, or almost total absence, 
of brain function at birth is quite likely due in great part to the absence 
of myelin in large brain areas. The tendon reflexes are present in the 
premature infant, and during the first year of life are more marked than 
in the adult. After the infant is ten days old the cutaneous, abdominal, 
and the plantar reflexes are very active. The Babinski reflex is 
normally present during the first six or eight months of life. 

Special Senses. — The pupils of the newborn respond normally to 
light, but the infant is not believed to have at birth the power to 
fix objects, and the power of accommodation does not appear until 
one month of age. The reflex closing of an eyelid at the approach of a 
finger is well developed at birth, but the true optical reflex of winking- 
is not seen until about the seventh week. At the age of one month 
the child is capable of fixing its eyes upon an object, and at four 
months can follow a moving object with its eyes. 



44 



NORMAL DEVELOPMENT OF THE CHILD 



In children horn before full term the swelling of the Eustachian 
tube often prevents the development of hearing for some days. 
Although the newborn infant cannot hear, the ability to do so develops 
within a few hours to several days after birth, hearing depending upon 
the time of entrance of air through the Eustachian tube into the 
internal ear. 

The sense of taste develops early, as is evidenced by the fact that a 
very young infant will often detect slight differences in its food; or 
will, perhaps, refuse water when accustomed to having a small amount 
of sugar added thereto. 

The sense of smell is little if at all developed at birth, but develops 
rapidly in the first few days of life. The sense of touch is one of the 
first to appear, and is always present at birth, the tactile tracts being 
supplied with myelin at the eighth month of fetal life. Appreciation of 
touch is especially noticeable in the lips, the introduction of any object 
into the mouth being usually sufficient to produce the reflex act of 
sucking. The newborn infant does not feel pain, is quite insensitive 
to the prick of a pin, and is probably entirely unable to appreciate the 
difference between external heat and cold, although heat and cold, 
as in the douche or plunge, exert a reflex influence. Sucking, swallow- 
ing, and ocular movements^ at birth probably do not depend upon any 
conscious mental effort, but are largely or entirely inherited reflexes. 

Speech begins to develop at about the tenth month, varying more or 
less in different children, and depending to a certain extent on the 
child's surroundings and management, but the tendency to induce 
infants to talk is certainly not to be encouraged. 

Stomach. — When the stomach is empty the pylorus occupies the 
lowest position, being found in the continuation downward of the mid- 
sternal line, or slightly to the left of this line. The cardia occupies 
a position on the left of the tenth dorsal vertebra, and is about one to 
one and a half inches (2 to 3.5 cm.) above the pylorus. The fundus is 
usually only fairly well developed at birth, and the capacity of the 
stomach at different ages is represented in the following table: 



At birth . . . 








1 dunce 


At two weeks 








2 ounces 


At one month 








3 


At two months . 








sy 2 " 


At three months 








4 


At four months 








4^ " 


At five months . 








5M " 


At six months 








6 


At seven months 








Q% " 


At eight months 








7H " 


At nine months 








8M " 


At ten months . 








9 


At eleven months 








9^ « 


At twelve months 








10 



30c.c 
60 c.c 
90 c.c 
100 c.c 
110 c.c 
125 c.c 
140 c.c 
160 c.c 
180 c.c, 
200 c.c 
225 c.c 
250 c.c 
275 c.c 
290 c.c 



The capacity of the stomach, of course, varies normally within 
considerable limits. The capacity of the infant's stomach at different 
ages is best obtained by estimating the average amount of milk in 



INTESTINE 45 

ounces usually taken by a child of a certain age or size. Children of 
the same age often differ greatly in size, and the larger the child the 
larger, as a rule, is the stomach. In deciding upon the amount of food 
to be given to a child at a single meal it must be remembered that a 
portion of the food taken passes out of the stomach during the swallow- 
ing of the meal, and that the tendency of the stomach is to empty 
itself of any food remaining from a previous meal as soon as the food 
of a subsequent meal is introduced, the rapidity with which this is 
accomplished depending largely upon the composition of the food and 
its amount. If a milk mixture contains a high percentage of fat, it 
tends to pass more slowly out of the stomach than a mixture with less 
fat and more protein and sugar. 

In the young breast-fed infant the stomach empties itself in one 
and one-half to two hours, this depending upon the size of the meal. 
An infant fed on the bottle will take an hour longer to empty its 
stomach than does the breast-fed baby; that is, two and one-half 
to three hours. The normal reaction of the stomach at birth is neutral 
or acid, but is always acid after taking either breast or cows' milk, 
owing to the secretion of hydrochloric acid. This is present one and 
one-half to two hours after a meal in 0.1 per cent, solution in healthy 
breast-fed infants. In bottle babies free hydrochloric acid may not 
be found, owing to the greater ability of cows' milk to combine with 
acids. The contents of the stomach of the breast-fed baby, containing 
more free hydrochloric acid, are therefore more antiseptic than in the 
bottle-fed. Lactic acid is also present in the infant's stomach during 
digestion. A fat-splitting ferment is also found, but its presence is 
probably of comparatively little importance. The milk, sugar, and 
water are the first elements of the food to pass through the pylorus, 
and are followed in turn by the albuminoids and the fats. Only a small 
amount of salts, sugar, and protein are absorbed from the stomach. 
Rennin is normally present in the stomach, and produces coagulation 
of the casein, the hydrochloric acid dissolving the curds. The coagula 
of cows' milk are larger and firmer than those of human milk, and are 
dissolved with more difficulty than are the lighter curds of human 
milk. 

Intestine. — The length of the intestine in the newborn is about seven 
to twelve feet (200 to 400 cm.). The muscular coat is, as a rule, poorly 
developed, in the infant, whereas the ^solitary follicles and Peyer's 
patches are relatively better developed. According to Or ban and 
Weinland, a ferment lactase is found in the secretion of the small 
bowel capable of decomposing lactose. 

The pancreas of the newborn has a moderate diastatic action, as 
well as a distinct fat and protein-splitting function. 



CHAPTER III. 
THE CLINICAL EXAMINATION OF SICK CHILDREN. 

In examining an ill child, it is absolutely essential never to hurry. 
It may be necessary to coax, amuse, or divert an infant; but the 
primary idea is not to frighten it, and the presence of any stranger in 
the room is often sufficient to upset the delicate nervous organism of 
an infant or even an older child. The early portion of the visit should 
be taken up by questioning the mother or nurse, first carefully eliciting 
the family history, subsequently the personal history of the child, 
and then the history of the present illness. 

Family History. — The family history should include the possibility 
of syphilis, tuberculosis, alcoholism, or rheumatism; the number of 
pregnancies; the number of children living and in health; or, if sick, 
from what they are suffering; the number of children dead and the 
causes of death. The hygienic conditions of the child's previous 
environment should be inquired into. Has it been an open air or a 
coddled baby? Has it been recently exposed to any communicable 
disease? At what age was the first tooth cut, and how many teeth 
has it now? When did the child creep, stand alone, and walk? Was 
the child asphyxiated at birth, did it breathe and cry immediately 
after birth, or were efforts to resuscitate it necessary ? How long was 
it breast-fed, wholly or in part, and what exactly was the strength of 
the modified milk mixtures or other food given it? What has been 
its diet since weaning? If any records of the child's weight have been 
kept, they should be carefully studied. 

All this information may be secured in a few minutes, and included 
in the child's history at the first visit; the few minutes so employed 
are not wasted; once obtained, it becomes a permanent record, and 
is often of paramount importance in establishing a past or present 
diagnosis. Furthermore, during this time the infant or older child 
becomes accustomed to the physician's presence. 

Inspection. — If possible the child should always be examined when 
asleep. The natural instinct of the mother or nurse is immediately to 
arouse the child upon the physician's arrival. Much information may, 
however, be secured by observing the child while he is asleep, and 
by studying the facial expression, which may indicate a quiet, relaxed, 
nervous system, or pain and tension. The child's mental powers can 
be gauged and compared with well-known standards. 

Note the child's general development, the appearance of the head, 
whether hydrocephalic, microcephalic, or asymmetrical. Observe 
whether there is a bulging or sunken condition of the anterior 
fontanelle. 



I'ALPATION 47 

The child's color should be noted; cyanosis may suggest congenital 
heart disease; puffiness of the eyes a possible acquired endocarditis 
or nephritis; pallor an anemia, probably secondary. Is the face 
pinched and toxic, or is it of normal contour and good color? Inspec- 
tion may disclose the absence or presence of enlarged glands of the 
neck. It may also show any abnormality of development in the contour 
of the abdomen and chest. A bulging in the precordia may suggest 
cardiac hypertrophy, or a systolic dimpling a previous pericarditis 
with adhesions. 

The development of the upper extremities should be compared with 
that of the lower, and the comparative size of the head and thorax 
noted. The eye should be examined as to the presence or absence of 
jaundice, also strabismus, nystagmus, or ptosis. The pupils are 
examined as to their size and their reaction to light. The history 
should include the presence or absence of pain, discharge, or odor 
in the ears. Many cases of restlessness, sleeplessness, and high fever 
may be in this way cleared up. Any nasal discharge should be noted. 
In very young children this may suggest syphilis, especially if it be 
persistent and blood-tinged. In an older child a nasal discharge may 
mean diphtheria; or, if it recurs frequently, possibly adenoids. If 
the discharge is recent, one-sided, and persistent the presence of a 
foreign body should be suspected. 

The respiration should be carefully observed as to whether it is 
rapid, or slow and irregular. Pneumonia may be suggested by the 
former and meningitis by the latter. Adenoids will be thought of if 
the child is a mouth breather, or if it snores. If there is cough (and in 
a child under two years of age there is, of course, no expectoration) 
a specimen of sputum may be obtained by passing a curved probe 
wrapped with cotton well back into the pharynx. Rachitis should be 
looked for in the spine, thorax, and extremities; the presence or 
absence of spinal or joint deformities which are not rachitic may 
assist in forming a diagnosis of tuberculosis. 

The posture of the child is sometimes significant. Continual 
lying on one side is suggestive of pleurisy with effusion. Lying im- 
movably on the back with the legs drawn up points to peritonitis. 
Sitting up in bed with the head thrown back indicates laryngeal 
obstruction. An eruption or desquamation may suggest one of the 
exanthemata; or, if desquamation alone exists, recent scarlet fever 
or syphilis. Syphilis may also be indicated by disease of the matrix 
resulting in suppuration and exfoliation of the nail. The dorsum is 
arched, and the nail appears as if it had been pinched by a pair of 
forceps, i. c, claw-shaped. Inspiratory dyspnea is shown by retraction 
of the suprasternal notch, the supraclavicular and intercostal spaces, 
and retraction of the abdomen. It should be noted whether the 
abdomen is distended or retracted. Cyanosis is suggestive of congenital 
heart disease, especially if combined with clubbing of fingers and toes. 

Palpation. — Palpation should always precede percussion, and usually 
precedes auscultation. The anterior fontanelle should be palpated. 



48 CLINICAL EXAMINATION OF SICK CHILDREN 

Is it large or small for the age of the child, and does it bulge or is it 
tense? Are the cranial sutures open or closed? In early infancy, if 
the child is emaciated and marasmic, the posterior portion of the head 
may show the presence of craniotabes (thinning of the infantile skull 
in spots) which suggests rickets or lues. 

Palpation may reveal the presence or absence of enlarged glands 
of the neck, or change in the size of the thyroid. An increase in tactile 
fremitus would suggest lung consolidation, pneumonic or tuberculous, 
while a decrease might indicate pleural effusion. Palpation may dis- 
close the existence of a cardiac thrill or murmur, and an enlarged 
or displaced heart can be diagnosed by displacement of the apex beat. 
The apex beat in the newborn infant may be felt higher than in the 
adult, this being partly due to the higher position of the diaphragm. 
On account of the greater breadth of the heart as compared with that 
of the chest, the apex is external to the mammary line, and remains 
so until the fourth year, and from this time to the ninth year it is in or 
near the mammary line. During the first year the apex beat is found 
in the fourth and, subsequently, as a rule, in the fifth intercostal space. 
A feeble apex beat does not in itself prove anything; it is sometimes 
hardly perceptible, even in healthy children, but the case is entirely 
different if it becomes weak or disappears during the course of some 
disease, when it indicates either imminent heart failure or the formation 
of pericardial exudation. 

The normal liver extends about one inch below the free border of 
the ribs, and if it is enlarged the increase in size may be disclosed by 
palpation. The spleen, if of normal size, is not palpable; hence, if 
demonstrable by palpation it must be enlarged. Bimanual palpation 
of the abdomen, the child lying on its back with the knees flexed, 
may enable one to recognize foreign masses in the abdomen; or, 
better results can sometimes be secured by digital examination per 
rectum. Bimanual examination with the finger in the rectum is often 
of advantage. By this method we may detect abdominal growths, 
enlarged glands, or a calculus. 

Dropsy in the face, abdomen, or extremities may be determined by 
palpation. Kernig's sign, i. e., inability to extend the lower leg if the 
thigh is flexed on the abdomen, and Babinski's reflex, i. e., extension 
of the great toe with spreading of the adjacent toes upon stroking the 
sole of the foot from the heel to the toes, preferably on the inner side, 
with a moderately sharp instrument such as a toothpick, may be of 
more or less assistance in confirming a diagnosis. It must be noted 
that the Babinski reflex is of value only in children over one year 
of age. 

Auscultation. — Auscultation in the child should, as a rule, follow 
palpation. Sometimes, however, it will be advisable to perform 
auscultation before palpation. Some children may be more willing 
to submit to the former than to the latter. It is well to auscultate 
the posterior surface of the chest first, and to use a stethoscope with a 
small bell when auscultating the axilla?. 



MENSURATION 4 ( J 

Percussion. — Percussion follows auscultation. It should always be 
performed gently, the posterior aspect before the anterior. On com- 
paring the two sides of the chest, the area of relative cardiac dulness 
and the area of absolute cardiac dulness in the infant and older child 
may be mapped out. The area of relative cardiac dulness is at the 
upper boundary of the second interspace, or the lower border of the 
second costal cartilage, at the left margin of the sternum. From this 
point the Jine of dulness extends in a curved direction outward and 
downward, the extreme left limit being at or slightly beyond the mam- 
mary line in the fourth interspace. On the right side, the line of dulness 
extends downward from the second interspace in a slightly curved 
direction along the parasternal line. The lower border is undetermin- 
able on account of the liver. 

The area of absolute or superficial cardiac dulness is that part of the 
heart not covered by the lung, resembling in shape the same area as 
in the adult, but being relatively longer. Its upper limit is the upper 
border of the third intercostal space, sometimes the third costal 
cartilage; it extends to the left to a point between the parasternal 
and the mammary lines, and to the right as far as the left border of the 
sternum. 

Percussion enables one to detect the presence of fluid in the abdo- 
men, and auscultatory percussion (percussing in the ordinary manner 
and listening over this area with a stethoscope) is often of advantage 
in pulmonary, cardiac, and abdominal conditions. 

Mensuration. — Mensuration enables one to compare the size of the 
head, thorax, and abdomen, although it must be remembered that 
temporary conditions often produce marked variations in abdominal 
measurements. The circumference of the head in comparison with 
that of the thorax, from birth up to fifteen years of age, has been 
tabulated on page 34. 

The length of the child is of importance. Infants and younger 
children are best measured by placing them in the recumbent posture, 
with a card or book vertically at the head and feet, then measuring 
the intervening space. For older children a measuring rod placed 
against the wall or the ordinary measuring rod that is attached to 
weight scales may be employed. 

The cry of the child may be of more or less assistance in locating 
the seat of the disease; the cry of pain may be sharp, acute, and 
accompanied by some attempt at localization, with contraction of the 
features; whereas young infants may be only restless and irritable. 
The cry of fright, as when a stranger enters the room, begins when such 
a person arrives and ceases when he leaves. The cry of pneumonia 
is short and catchy, i. c, an expiratory grunt; that in laryngitis is 
croupy; in extreme exhaustion or marasmus we hear only a feeble 
whine. A moaning cry suggests intestinal disease. In scurvy the 
child's cry is sharp, and occurs especially when it is touched. 



CHAPTER IV. 
INFANT MORTALITY. 

The modern tendency in medicine is to concentrate each individual's 
efforts within comparatively narrow limits; if possible, to add some 
new facts or theories to present knowledge. The sum total of all the 
additions and advances has revolutionized medical knowledge in 
the last twenty years. Countless intelligent and zealous physicians 
working along different lines and in special departments of medicine 
have made it difficult, if not impossible, for any one to keep fully 
abreast of the times in all branches of medical science. 

Perhaps this tendency in modern medical study has led to the 
neglect of certain broad principles of hygiene, diet, fresh air, bathing 
and general methods of living; these, being every one's business, 
have become no one's business. 

John Gardner, surgeon, London, wrote in 1838 an interesting 
pamphlet on "Why So Large a Number of Children Perish." He 
appreciated certain physiological differences between a child and an 
adult, and under "Dentition" wrote: 

The true nature of the effect of this natural process on the health 
and life of children is much misapprehended. In a healthy body, 
the teeth are always cut without suffering, and not far wide of the 
ninth month. The passage of the teeth through the gums produces a 
slight excitement, which is not a deviation from health. 

Benjamin J. Crew, of Philadelphia, wrote in 1882 an excellent article 
on "The Care of Deserted Infants," which was read before the assembly 
meeting of the Philadelphia Society for Organizing Charity in March 
of that year. In this article he strongly advocates a combination of 
" placing out" and " asylum plan" for these infants, and quotes statistics 
which clearly prove how great is the reduction in the mortality in 
infants under the plan of treatment advocated. 

J. Brendon Curgenven, M.R.C.S., London, 1867, writing on "The 
Waste of Infant Life," states that the excess of infantile mortality 
occurs in laboring people. The poorer and lower classes show a 
mortality of 35 to 55 per cent, under the age of five years; the educated 
and well-to-do, only 11 per cent. He analyzes the Registrar General's 
report, and shows clearly the causes of this excess of 24 to 44 per cent, 
of deaths. Reference will be made to these statistics later. 

In an article written by Dr. William Farr, over thirty years ago, 
he stated that the mean annual death rate of infants under one year 
in some of the principal countries of Europe was as follows: Out of 
one thousand infants there died yearly in Sweden 141.8; in Denmark, 
137.5; in England, 182.6; in France, 223.2; in the Netherlands, 237.5; 
in Spain, 249.6; in Italy, 273.3. 



GENERAL STATISTICS 51 

The annual death rate in one thousand children under five years, 
according to the same authority, was: In Norway, 40.9; in Sweden, 
51.4; in Denmark, 52.7; in England, 67.6; in Belgium, 74.9; in 
France, 79.2; in Prussia, 82.4; in Holland, 91.2; in Austria, 104.0; 
in Spain, 111.7; in Italy, 113.5. The United States census for 1910 
shows that 265,000 babies died during their first year and 53,000 
in their second year. 

A. Brothers, B.S., M.D., in 1896, in his article on "Infantile Mortality 
during Child-birth and its Prevention," states that in the four years, 
1889 to 1892, the total number of births in New York City was 1 73, 126, 
and that during this period of four years 16,888 children born at term 
had died within the age of one month. Ten per cent, of the children, 
therefore, are lost before they reach the age of one month. 

Collective statistics from sixteen European cities embracing 1,439,056 
children show that 10 per cent, of those born alive die within the first 
four weeks of life. Eross' statistics show that the greatest number of 
deaths occurred on the first day of life, and that the deaths diminish 
day by day. According to Eross, 54.24 per cent, of the deaths among 
children within four weeks after birth are due to congenital debility. 

Dr. Shaw, in the Albany Medical Journal, 1913, states that in the 
United States 300,000 babies die annually before they reach the age 
of twelve months. The ratio of infant mortality to births is 150 
to 1000; in other words, one baby in seven dies before it is one vear 
old. 

In New York State the death rate in these infants is. 121 to 1000; 
in Vermont, 145 to 1000; in Burlington, Vt., it is 230 to 1000; in 
London, England, 90 to 1000; in Great Britain, 130 to 1000; in New 
Zealand, 62 to 1000; in Chili, 331 to 1000; and in Russia, 240 to 1000. 

Phelps states that in England and Wales, in 1912, the death rate 
in infants born alive was 95 to 1000. 

William Moore, in a paper read before the Dublin Obstetrical 
Society in 1859, states that the proportion of deaths throughout 
England, under all ordinary conditions of life, is believed to be one in 
six within the first year. To parallel this proportion of mortality, we 
must pass on to those dying between the ages of 80 and 85. 

Dr. D. Meredith Reese, of New York, reported at the meeting of 
the American Medical Association in May, 1857, that nearly 50 per 
cent, of the total deaths in large cities occurred in children under five 
years of age. In New York City in the fifty years, 1804 to 1853, the 
whole mortality was 363,242, including stillbirths, and during this 
period 176,043 children under the age of five years died— nearly 49 
per cent, of the entire number of deaths. 

M. Bertillon stated before the Academy of Medicine of Paris that 
in a period of ten years there had been in France 9,700,000 births; 
of those born 1,500,000 died within the first year of life. 

Morse makes the statement that 85 per cent, of all infants who 
die are bottle-fed babies, and that 90 per cent, of all deaths due to 
diarrheal conditions occur in those who are bottle-fed. 



52 INFANT MORTALITY 

J. Maule Sutton, M.D., of London, in 1872, drew attention to the 
influence exerted on infant mortality by the social status of the parents. 
His figures give a mortality of 77 per thousand for children under one 
year of age in urban population; and a lower percentage for rural 
population. These same districts, excluding the upper-class births, 
gave a mortality of 158 per thousand. He studied the infant mortality 
among the children of the farmers of Devonshire and Norfolk, two 
agricultural counties, and found it to be 95 per thousand in the 
farming class; the rate among the children whose parents were not 
farmers was 130 per thousand. 

John S. Parry, M.D., of Philadelphia, in 1871, quotes Dr. A. Jacobi 
as saying that "of 100 infants born alive to the gentry of England 
(1844) there died 20; to the working classes, 50. In the aristocratic 
families of Germany there died in four years 5.7 per cent.; among 
the poor of Berlin, 34.5 per cent. In Brussels the mortality, up to the 
fifth year, was 6 per cent, in the families of capitalists, 33 among 
tradesmen and professional people, and 54 among workingmen and 
domestics." Quoting de Villiers, he further writes that "the mortality 
among the children of the workingmen of Lyons is 35 per cent., and 
in well-to-do families and agricultural districts it is 10 per cent." 

Dr. George Reid, in 1906, in London, at the National Conference on 
Infant Mortality, in considering social status as an etiologic factor, 
divides the working class into three groups: (1) Those among whom 
the proportion of employed, married and widowed females between 
eighteen and fifty years of age reached or exceeded 12 per cent.; 
(2) those among whom the proportion was 6 to 12 per cent.; (3) those 
among whom the proportion was below 6 per cent. The decades, 1881 
to 1890, 1891 to 1900, and the four years, 1901 to 1904, were studied. 
The infant mortality was always highest in group 1 and lowest in 
group 3. The average yearly infant mortality rates of group 1 were 
195, 212 and 193; group 2, 165, 175, 156; group 3, 156, 168, 149. 
These statistics point out in no uncertain manner the fact that the 
infants of women employed in industrial and manufacturing plants 
during the time of their married life and motherhood are born into this 
world with less chance of battling with the problem of living than 
those whose mothers are not compelled to perform this kind of work. 
The wives of farmers may and often do perform hard work, but it is 
done more or less out of doors, and not in the vitiated and contaminated 
atmosphere of a mill or factory. 

Helle examined into the social status of the parents of 170 infants 
dying in Graz during 1903 and 1904; 112 infants who died had very 
poor parents; 49 children had poor parents; 9 had well-to-do parents, 
and no deaths occurred among the children of the rich ; the percentage 
of the four classes being 65.9, 28.8, 5.3, 0. The general infant mortality 
in Graz has markedly decreased in the last twenty years, while the 
mortality due to gastro-intestinal lesions does not show any marked 
diminution. 

In Brun, a city of 110,000 inhabitants, the health statistics for 
fifteen years show that the general infant mortality during this time 



GENERA I STA TISTICS r>' ' 

decreased very much, while that due to gastrointestinal lesion- 
changed very little. 

In Berlin, 1903, Newman investigated 2701 infant deaths. Where 
the families were in one-room dwellings he found 1792 deaths; in two- 
room dwellings, 754 deaths; in three-room dwellings, 122 deaths, and 
in larger dwellings, 43 deaths. It seems to be an established fact that 
the percentage of deaths among infants of the poor largely exceeds 
the mortality among the infants of the rich. 

The hygienic surroundings of the infant — city or country life — 
are factors which play an important part in the sum total of infant 
mortality. In England and Wales, 77 per cent, of the whole population 
is urban; fifty years ago the population was equally divided between 
urban and rural districts. A considerable portion of this urban popu- 
lation lives in small towns, more closely resembling country than city 
life. In the year 1904, in England and Wales, 59.1 per cent, of the 
people lived in large towns of over 20,000 inhabitants; in 1801, only 
1G.7 per cent, lived in large towns. 

It seems clear to me that this tendency to live more in large towns 
has much to do with the stationarv infant mortality in England and 
Wales. City life means for the parents, often, long hours of work in 
a factory or mill; living in a small house in a small street, often poor 
food, and not uncommonly dissipation of drink and perhaps immorality. 

Epidemic diarrhea is mostly a disease of large towns and cities. 
It can be positively stated that geological strata, character of soil and 
climate have nothing to do with infant mortality, nor is it entirely 
a question of poverty. Overwork, poor hygienic surroundings, and 
poor housing seem to be two powerful factors causing infant deaths. 
Density of population per se may and does mean a good deal in causing 
deaths in infants. Urban England has a higher infant mortality than 
rural England. However, in first-class modern houses, the popu- 
lation may in a given area be dense, but the infant death rate may be 
small if other factors are present, as good hygiene, food, fresh air, 
healthful occupations and good social status. 

If a town is distinctly industrial or manufacturing, the mortality 
invariably exceeds that of the town where the occupations have more 
of an agricultural tendency. Table 1, by Newman, shows the infant 
mortality in the country of Wiltshire, in which there are no large towns; 
it shows also that even under favorable conditions the city mortality 
exceeds the rural mortality; it also shows the high mortality of large 
towns, and the mortality of England and Wales, and rural England 
and Wales. 

Table 1. — Infant Mortality Rates in Wiltshire and England and Wales, 

1900-1904. 
Districts. 1900. 1901. 1902. 1903. 1904. 

County of Wiltshire . 
Urban districts (Wilts.) . 
Rural districts (Wilts.) . 
England and Wales . 
Large towns in England . 
Rural England and Wales 



94.0 


93.7 


97.23 


85.63 


95.99 


95.6 


106.8 


93.63 


89.27 


100.32 


115.7 


83.8 


99.89 


82.76 


92.52 


154.0 


151.0 


133.0 


132.0 


145.0 


172.0 


168.0 


145 . 


144.0 


160.0 


13S.0 


137 . 


135 . 


1 IS . 


125.0 



54 INFANT MORTALITY 

In these two countries the highest infant mortality occurs in large 
towns; next, in large towns and rural districts; and the lowest mor- 
tality in rural districts. 

Table 2, by Newman, shows the remarkable difference in infant 
mortality in three agricultural counties, five mining and manufacturing 
counties, and three towns where textile industries and mining are 
largely followed. 







TABLE 


2. 










Of 100,000 infants born, the number Annual death rates 


per 1,000 living 




surviving at each age. 


in 


each successive 


interval of 


age. 




_ © c 


ig and 
;uring 

Staffs., 

3..W.R. 

rham. 






M 

'3 
1 


CO 

o 


Age. 


2WP 


minir 
ufad 
ties: 
,Lanci 
:s, Du 


M P-i a 

•■£i . 

22^ ^ 


© 

© . 
U CD 


© ® 


CD 




© 02-iS 


fl C ri-* 


© Co © 


c 


a 






H 4 ^ 


Five 
ma 
cou 
Leii 
Yoi 


Thre 
tow 
Bla 
cest 


ai 


«8 


0J 


At birth . . 


. . 100,000 


100,000 


100,000 


213 


331 


382 


3 months . 


. . 94,820 


92,051 


90,874 


75 


154 


240 


6 months . 


. . 93,068 


88,574 


85,574 


61 


128 


180 


12 months . 


. . 90,283 


83,081 


78,197 









This table covers the three years, 1889 to 1891, and shows that of 
100,000 infants born in the rural counties 10,000 died; in the manu- 
facturing counties 17,000 died, and in the manufacturing towns, 22,000. 
An important point to notice in this table is that the town rates are 
most in excess of the rural rates in the later months of the first year 
of life, showing clearly that the congenital conditions, atrophy and 
immaturity, can be left out of consideration, and that the continuous 
ill effect of town life finally kills many children that have made a strong 
but useless struggle against their environment. Epidemic diarrhea 
plays a powerful part in this sacrifice of infant iife in those towns 
where textile industries, manufacturing and mining, flourish. 

The deaths occurring during the first year of life are very unevenly 
distributed. This applies to all countries, and all statistics that I 
have been able to find prove it absolutely. The greatest percentage 
of deaths occurs in the first three months of life, and I believe that this 
percentage is increasing and not decreasing. In London during the 
years 1839 to 1844, 24,354 infants died during the first three months 
of life, an infant death rate of 68 per thousand. In the same city in 
the years 1898 to 1903, 56,963 infants died during the first three months 
of life, a death rate of 72 per thousand. According to Newman, 
there has been, in recent years, an increased percentage of infant 
deaths in England and Wales during the first three months, and a 
slight decrease in the percentage of deaths during the last six months 
of the first year. Newman asserts that infants die more from im- 
maturity at the present time, and that - consequently more infants 
begin life with less vitality than in former periods. He also states: 
" Children under twelve months of age die in England today, in spite 
of all our boasted progress and in spite of an immense improvement in 



GENERAL STATISTICS 



55 



the social and physical life of the people, as greatly as they did seventy 
years ago." 

The report of the Registrar General of England, for 1^03, shows 
for England and Wales, 51.4 per cent, of infant deaths in the first three 
months; 19.9 per cent, in the second three months, and 28.7 per cent, 
in the last six months of the first year of life. In the year 1904, in 
Berlin, 53.6 per cent, of deaths of infants under one year occurred in 
the first three months. These deaths are, of course, distributed over 
the entire calendar year, and this observation consequently is not 
contradicted by the fact that the greatest number of deaths was in 
the hot months. Births occur in each month with fair regularity, and 
the congenital conditions which contribute so largely to this mortality 
in the first few weeks of infant existence are consequently distributed 
with fair regularity throughout the year. 

Morse classifies the causes of infantile mortality as follows: 



Per cent. 
Prematurity, congenital debility, congenital defects, accidents at birth 25 

Acute gastro-intestinal diseases ^5\ , n 

Diseases of nutrition 15 

Acute respiratory diseases 

Acute infectious diseases .... 3 

Tuberculosis 2 

Syphilis ....... 1 

Unclassified 9 



The following table shows the causes of infant mortality in Phila- 
delphia during the year 1915: 



Disease. Under 

one year. 

General diseases 118 

General diseases, non-epidemic 181 

Diseases of the nervous system 113 

Diseases of the circulatory system • . . . 27 

Diseases of the respiratory system (pneumonia excepted) . . 145 

Pneumonia, all forms 59S 

Diseases of the digestive system (diarrhea and enteritis excepted) . 124 

Diarrhea and enteritis 116S 

Skin diseases ' 34 

Diseases of the genito-urinary system 10 

Diseases of the locomotor system 2 

Malformation and early infancy 1560 

Violence 40 

Injuries at birth 99 

Ill-defined 1 

Totals • 4220 



One to two 
years. 

195 

82 

17 
8 

45 
293 

32 
213 
1 
7 
2 
9 

25 



via; 



During the year 1914 there were 41,063 births reported in 
Philadelphia and 1929 stillbirths registered as deaths. The causes 
of infant mortality in Philadelphia for the year 1914 were as follows: 



5(> INFANT MORTALITY 

INFANT MORTALITY— AGE PERIODS UNDER ONE YEAR. 

Under 1 1 week to 1 to 3 3 to (5 6 to 12 
Diseases. Total. week. 1 month, months, months, months. 

Total 49S1 1125 750 839 930 1337 

General diseases, epidemic . . 208 2 12 30 41 123 

General diseases, non-epidemic . 179 16 25 30 47 61 

Diseases of nervous system 81 20 11 15 20 15 

Diseases of circulatory system .10 3 1 4 2 
Diseases of respiratory system 

(pneumonia excepted) . . . 220 11 35 45 55 74 
Pneumonia, all forms ... 733 19 80 150 173 311 
Diseases of digestive system (di- 
arrhea and enteritis excepted) 138 6 12 22 32 66 
Diarrhea and enteritis . . . 1474 14 143 303 442 572 
Diseases of genito-urinary system 14 2 3 6 1 2 

Skindiseases 32 10 10 1 11 

Diseases of locomotor system . 3 .... .... 1 ... 2 

Malformation and early infancy 1736 946 395 206 106 83 

Violence 50 6 5 12 12 15 

Injuries at birth 101 80 16 5 ... .... 

Ill-defined 2 2 

Living at birth 41,063 

Stillbirths registered as deaths 1,929 

The added deaths from gastro -intestinal disease, occurring as they 
do in great excess in the hot months, cause the great increase in the 
total infant mortality for the heated term. 

Schereschewsky gives us the following figures to show the effect of 
heat on infant mortality : 

The number of deaths in Berlin in July and August of 1910 (a cool 
summer) was 1439, while in July and August of 1911, which was a 
very hot summer, 2050 infants died. The universally hot summer of 
1911 in Europe caused a clearly demonstrable rise in the number of 
deaths in infants in every locality where statistics were compared. 

The following table of deaths from diarrhea and enteritis shows the 
increase in infantile mortality during the summer months of 1914 in 
Philadelphia : 

MORTALITY IN INFANTS UNDER ONE YEAR OF AGE. 





Jan. 


Feb. 


Mar. 


Apr. 


May. 


June. 


July. 


Aug. 


Sept. 


Oct. 


Nov. 


Dec. 


Breast-fed . 


8 


9 


13 


9 


10 


7 


8 


28 


22 


18 


11 


10 


Artificially fed 


21 


14 


15 


13 


* 16 


4 


155 


148 


104 


56 


36 


24 


No data as to 


























feeding 


9 


18 


21 


17 


27 


50 


138 


161 


71 


73 


36 


34 


Totals 


38 


41 


49 


39 


53 


61 


301 


337 


197 


147 


83 


68 



The outside and home employment of mothers is a factor in infant 
mortality that was appreciated long since, and led Sir John Simon in 
1856 to state that "infants perish under the neglect and mismanage- 
ment which their mothers' occupation implies." In Dundee a large 
percentage of the female population of girls and married women 
work in the jute and hemp factories. The labor is unskilled, the wages 
small and the hours 6 a.m. to 6 p.m. These women and girls are, as a 
class, subnormal in weight and general physical development; many 



GENERAL STATISTICS 

of the children arc born and raised in houses containing only one or 
two rooms, or in large tenements, where overcrowding and, usually, 
uncleanliness exist. In the ten years, L893 to L902, the infant mortality 

was 176 per thousand births; in 1904, out of 174 deaths, 12.") were due 
to prematurity and immaturity, and over 49 per cent, of the deaths 
occurred in the first three months of life. 

In England the Factory Act of 1901 states : " An occupier of a factory 
or workshop shall not knowingly allow a woman or girl to be employed 
therein within four weeks after she has given birth to a child." This 
is positive legislation of a far-reaching character. If the hygienic 
conditions of air, light and cleanliness were only adequately controlled 
by law in these mills or factories, and such provisions for sanitary 
surroundings as are needful were insisted on, much could be done to 
remove the injurious influences of this cla^> of employment. Much 
has already been accomplished in this direction, but much >till remains 
to be done. 

In Kearsley, a town of Lancashire, of 9500 population, the infant 
death rate increased from 179 per thousand in 1894 1903 to 192 in 
190:;, and 229 in 1904; and this is due, according to J. C. Eames, M.J)., 
medical officer of the town, to the town having "developed into more 
of a manufacturing district." 

In Mulhouse, Mr. Dollfus, who owned a large cotton mill, established 
a fund to which all the married women subscribed, and he personally 
contributed. Each woman subscribing received from the fund sufficient 
for her support during the two months following her confinement. 
On resuming work at the end of this two months, she was granted time 
at midday to return home and care for her baby. This procedure 
alone reduced the infant mortality more than 50 per cent. 

In 1876 there was established in England a Society for Nursing 
Mothers. The object of the Society is to save the child's life by 
preserving the health of the mother. The mothers are cared for in 
institutions for several weeks before confinement, being well fed and 
housed; but, what is more important is that, during the first year of 
the child's life, the mother is cared for wholly or in part, as it is neces- 
sary. A physician and nurse visit her at her house and give her 
the assistance she may require. Each month the child is weighed, 
thoroughly examined, and if sick is always taken care of. The Society 
has cared for over forty thousand children, and the saving of infant 
life has been very great. 

In Paris since 1904 the Coullet dining-rooms have gone one step 
ahead of anything done, as far as I know, in America. They have 
established restaurants in the poorer districts of Paris ; any woman who 
is nursing a baby is given free of all cost two good meals each day. 
They feed the mother, and the mother nurses the baby. 

Since all empires are built of babies, unless a change in the trend of 
statistics of infant mortality shall take place, our future generations 
will fail to develop physically and numerically along the lines which 
are both normal and natural. Race suicide is not a theorv, but a fact. 



58 INFANT MORTALITY 

France is actually facing slow extinction; its birth rate is smaller than 
that of any other European nation. The trouble and expense incident 
to the care and rearing of children does not appeal to all women of the 
present day; motherhood is not always synonymous with wifehood. 
A high birth rate is usually, but not invariably, linked with prosperity. 
The foreign-born population of the United States has apparently 
a larger percentage of children than the native population, but this 
excess of fecundity is probably no more than that which usually is 
found in urban populations in poor districts, and the high infant 
mortality commonly found among this foreign element more than 
reduces its growth to the level of native-born Americans. 

The Royal Commission in New South Wales, quite recently appointed, 
after careful study and thought, decided that the main factor in the 
reduction of the birth rate was : " A diminution in fecundity and fertility, 
in recent years; due to the deliberate prevention of conception and 
destruction of embryonic life, and to pathological causes consequent 
on the means used, and the practices involved therein." The remedy 
for this is not easy to apply; all nations are becoming more extravagant 
in their methods of living — automobiles and babies may be incompatible 
possessions — if we have one, we must often renounce the other. 

Infanticide by neglect or intention undoubtedly causes the death 
of many hundreds of infants each year. Women in the poorer walks of 
life should be urged to nurse their children, entirely or in part, as long 
as possible. Part breast- and part bottle-feeding is much better than 
all bottle feeding; weaning should never be done prematurely unless 
by the advice of a physician. Women with illegitimate children should 
be kept in the hospital and made to nurse their babies until after the 
third month. After this age, the child is better able to withstand the 
perils of artificial food, and the mother, from her association with the 
child, has perhaps become sufficiently fond of it to make an effort to 
protect its life. If a child is born, and no one is with the mother at 
the time of its birth, the danger of death at the time of delivery is 
greatly increased, and the secrecy of birth may induce the mother, 
under certain conditions, to destroy the child's life. 

The giving of opiates to children, either in the form of paregoric 
or of a soothing syrup, is pernicious and should always be absolutely 
forbidden. Overlying, either by accident or design, is in certain 
portions of this and other countries very common; an infant, of 
course, should never .sleep in the same bed with its mother. 

Infant life insurance and burial clubs cause the death by neglect 
of many; statistics prove that a much greater number of children 
insured and in burial clubs die than of those children in the same cities 
and towns who are without such insurance. Coroners' inquests should 
be rigid and impartial, and if there is any question or possibility of 
infanticide, the case should be thoroughly investigated and proper 
punishment imposed on the guilty. Of 864 children dying under one 
week of age in Philadelphia, inquests showed, according to Parry, 
that 94 were "stillborn," 210 died from "unknown causes," 293 from 



GENERAL STATISTICS 59 

"asphyxia," 62 from "exposure and neglect," and 2'1 from "want of 
medical attention/' In these eases the coroner's physician believed 
that the majority of those which he examined were murdered. 

The death rate per thousand is well known to be much higher among 
illegitimate than among legitimate children. An interesting fact, 
which is perhaps not always appreciated, is that in large cities the death 
rate among illegitimate infants is much greater than in country districts. 
In Glasgow in 1873 the death rate for illegitimate infants was 293 
per thousand; for legitimate infants, 154 per thousand. In London 
in 1902 the death rate of illegitimate children was almost twice as 
great as the death rate of legitimate children. The infant death rate 
of London, as a wdiole, exceeds the rural infant death rate by about 
20 per cent. The deaths among illegitimate infants in London exceeds 
the rural death rate among illegitimate infants by over 50 per cent. 

According to Dr. Norman Kerr, in 1S94 the proportion of female 
inebriates in England had increased greatly in the few years preceding 
1894. He asserts that prison experience shows a distinct increase in 
excessive drinking among women. According to the annual death rates 
from alcoholism in England and Wales, per million living, from the 
year 1875 to 1904, the mortality due to inebriety is distinctly increasing. 
The average for every five years from 1875 to 1904 was: 1875 to 1879, 
25 deaths per million living; 1880 to 1884, 29 deaths per million; 
1885 to 1889, 36 deaths; 1890 to 1894, 50 deaths; 1895 to 1899, 58 
deaths; 1900 to 1904, 71 deaths. In studying these figures it seems 
as if there can be no reasonable doubt that alcoholism is increasing 
among the women of England and Wales, although some allowance 
should probably be made for the more accurate diagnosis of recent 
years. Dr. Scott, quoted by Newman, believes that alcoholism is 
increasing among the women of Scotland. 

Alcohol is a distinct poison to children, but the number of deaths 
caused by the giving of alcohol direct in any form to children is certainly 
very small in the United States. It has, however, been clearly shown 
that suffocation in bed and overlying are twice as common on Saturday 
as on any other night in the week; and the prevalence of drinking 
among the poor on that night is proverbial. An alcoholic mother 
rarely supplies her baby with a good breast milk, and what is perhaps 
more important is the fact that the milk from such a mother may even 
contain alcohol. Alcoholism among women is perhaps increasing in 
America, but it is surely less common than in England. 

Systematic nursing and medical care are wonderful aids in the 
prevention of infant mortality, and account largely for the difference 
between the infant mortality of the rich and poor. Home treatment, 
or perhaps better say maltreatment, of very young infants often 
destroys what little chance of life the infant would otherwise have had. 
The poor and ignorant classes often call "the doctor" too late to save 
the patient. 

It is not an easy task to form an accurate idea of how many or what 
proportion of infant deaths are due to congenital causes and those 



60 INFANT MORTALITY 

diseases which, if not actually congenital, still leave the child more 
susceptible to their development than is the child whose parents are 
free from such diseases. Herbert M. Rich, in 6866 deaths under one 
year of age, found 23.2 per cent, to be due to malformations, congenital 
debility and premature birth. 

In Philadelphia during the year 1915, 70 deaths were recorded in 
infants under one year of age as due to syphilis, and 4 deaths in infants 
from one to two years of age from the same cause. During this same 
year there were 848 premature births in Philadelphia, a large por- 
portion of which, it is reasonable to suppose, w T ere due to syphilis, 
which is certainly responsible for many premature and early deaths. 

During 1911 and 1912, in New York City, there were 132,776 births, 
of which 6749 were stillbirths. 

The following figures are from the records of the Board of Health 
of New York City: 





No. of births. 


Stillbirths. 


Illegitimate births. 


Deaths one 

month and 

under. 


11 . 

12 . 


. 66,537 
. 66,249 


3438 
3311 


1559 
1541 


8223 
7675 



In London and in most English cities the mortality from prematurity 
and atrophy is about 45 per thousand, these deaths almost all occurring 
in the first three months of life. Smallpox, malaria, typhoid fever 
and tuberculosis are all diseases that may and do exert an influence on 
the infant. Lead, mercury and phosphorus may have a distinct 
antenatal effect, and the influence of alcohol has already been alluded 
to. In fact, any and all toxemias may influence the child during 
mtra-uterine life. 

The table on page 61 gives the causes of death in babies less than one 
month old during the year 1912 in New York City. 

Gastro-intestinal diseases are not only the most common diseases of 
infancy and childhood, but they are also responsible for more deaths 
than any other class of diseases. Infantile diarrhea is especially apt 
to occur in the first year of life, although very common in children 
under two years of age. Hot weather, bad feeding and poor hygiene 
are the chief etiological factors. It is often seen in epidemics, is very 
dangerous, and is the common cause of deaths among infants in cities 
in summer. Epidemics have often been traced to infected milk, 
although one must remember that milk may be infected at the farm, 
in transit, or by the consumer. 

Cases of this disease are rare among the rich, compared to the 
number one sees among the poor; they are rare in the country, com- 
pared with the number seen in the cities. The diarrheal death rate 
is, as a rule, highest in those countries where the infant mortality is 
greatest. Taking 42 of the largest German cities, in the years 1904- 
5-6, there occurred 67,633 deaths of infants under one year of age; 
of these 28,422 were due to gastro-intestinal disease. 

The records of the Bureau of Health of Philadelphia for the year 



GENERAL STATISTICS 



61 



1915, show the number of deaths from diarrhea and enteritis, as 
follows: 

Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec. 
Under one year 32 27 42 54 47 49 201 269 217 122 69 

1 to 2 years . 5 



6 



in 



37 



60 



11 



15 



This gives a total of L163 deaths in infants before the end of the 
first year, and only 213 deaths during the second year. 





Jan. 


Feb. 


Mar 


Apr. 


May June 


July 


Aug. 


Sept. 




Nov. 


Dec. 


Total 


Erysipelas 


1 


2 


4 


3 





3 


3 


2 








1 





Pi 


Congenital debility, 


























icterus, at rophy, pre- 


























maturity, marasmus 


120 


113 


120 95 


13 4 


111 


1 25 


121 


121 


121 


1(12 


10.". 


1388 


Gangrene 





1 




















o 








1 


Syphilis .... 


6 


4 


6 !> 


4 


3 


3 


2 


3 


4 


8 


5 


57 


Gonococcus . 














1 


o 














o 


1 


2 


General diseases, pur- 




























pura hemorrhagica, 




























diabetes 


1 








ii 


























1 


Convulsions . 


8 





3 


1 


2 


."> 


3 


4 





1 





2 


- 


Bronchitis 


13 


6 


8 


■2 


4 





2 


3 


:•! 


5 


•"> 


" 


56 


Pneumonia . 


28 


26 


n 


26 


li 


8 


10 


10 


10 


21 


26 


22 


207 


Influenza 


1 





o 





























1 


Pertussis 
































2 





2 


Diarrhea, enteritis . 


4 


6 


13 


11 


11 


7 


14 


13 


14 


10 


4 


7 


114 


Diseases of stomach 























o 











3 


3 


Hernia and intestinal 




























obstruction 





1 


1 

















o 








1 


3 


Congenital malfor- 




























mations . _ . 


13 


11 


20 3 


17 


12 


16 


11 


s 


17 


15 


13 


156 


Diseases of skin and 


























adnexa . 


1 


o 


1 1 





1 


1 














1 


6 


Diseases of kidney . 





o 


.» 























1 


1 


Diseases of liver. 


o 

















1 














1 


Meningitis 





























1 





1 


Softening of brain 




















1 














1 


Tetanus .... 


3 

















1 








o 


o 


4 


Causes peculiar to 


























infancy, umbilical 


























hernia, atelectasis, 


























forceps injury . 


43 


47 


50 


38 


45 


31 


:•!.-, 


37 


20 


A.; 


31 


37 


459 


Homicide, piercing. 




























cutting .... 


1 











1 














1 








3 


Homicide, other 




























means .... 


1 





4 





2 


1 


o 











1 





10 


External violence 


2 


1 


1 








1 




















5 


Accidental drowning 


1 














1 


o 








2 








4 


Absorption of delete- 




























rious gases . 


1 


1 











1 











1 


1 


5 


Acute poisoning 


























o 


o 








Acute abscess 








3 


o 


o 

















1 


4 


Diseases of organs of 


























locomotion . 























1 








II 


1 


Diseases of lymphatic 


























system .... 
































o 





Unspecified causes . 





1 











o 


o 


" 











1 



In certain American cities it has recently been clearly proved in 
many instances that this enormous summer death rate, due to the 
diarrheal diseases, can be reduced. Clean milk must be provided for 
the poor at a nominal cost, and this milk must be properly modified 
for children of different ages and conditions. A campaign of education 
among the mothers of this poor class must be carried on persistently 
and continuously; visiting nurses must be supplied; and fresh air and 
improved hygiene must be insisted on. It is not asserting too much 
to say that a reduction of 50 per cent, in summer infant mortality may 
be accomplished by these means. 

It is an old truth thoroughly appreciated by American physicians 



02 INFANT MORTALITY 

that breast-fed infants do well, whether they belong to the rich or the 
poor, but I do not believe that it is appreciated how great a difference 
exists in the infant mortality between breast-fed and bottle-fed infants. 
In the year 1903, 4075 infants died in Munich; of these 83 per cent, 
were artificially fed. In Berlin since 1885 the census gives the character 
of the feeding of all living children. Taking the five years, 1900 to 
1904, only 9 per cent, of the deaths occurred in breast-fed babies, and 
Budin has shown that only about 9.5 per cent, of the infant mortality 
in Paris occurs in breast-fed children. Of course, breast feeding is 
usually associated with other favorable factors, and bottle feeding 
often combined with many unfavorable associated conditions, but the 
figures are truly startling. 

The importance of breast-feeding as a means of reducing the infant 
mortality rate is clearly shown by the statistics which follow : 

In New York City more than 85 per cent, of all deaths in infants 
occur in the bottle-fed. In Boston, in the year 1911, 74 per cent, of 
all infants over two w T eeks of age who died were artificially fed, and in 
a series of 1000 cases of infants studied by Armstrong, in Liverpool, 
22.8 per cent, of the artificially fed babies died in their first year, and 
only 8.4 per cent, of the breast-fed. In 1908 the Health Department 
of New York City reported that of 1000 fatal cases of enteritis only 
90 were in breast-fed infants. 

In war time the infant mortality often declines in manufacturing 
centres, in spite of the fact that the general mortality rate increases. 
During the siege of Paris, 1870-71, it is claimed the general mortality 
rate doubled, yet the infant mortality rate declined 40 per cent. 
Under such conditions infants do not die, and why? In times of war 
or great industrial depression the poor woman , having no work, stays 
at home and nurses her baby, and the child lives. In prosperity she 
works all day, gives her baby the bottle, and it dies. 

This is borne out by recent statistics compiled in Paris where, since 
the beginning of the present war, the general infant mortality has 
diminished, more babies are born at full term, and fewer are abandoned. 
These conditions must be attributed to the special protection extended 
to expectant mothers and to infants during the first year of the war. 

In England this work of saving the babies has received a great 
impetus since the outbreak of the war, more infant welfare stations 
having been established than ever before in the same period of time. 
During the first eight months of the war 100 new schools for the instruc- 
tion of mothers were founded, many of which furnished meals for both 
expectant and nursing mothers, while 200 more baby stations were 
planned for; all this in towns with a population of 20,000 or more, to 
say nothing of what the smaller places may have done. 

It is both interesting and instructive to note that any considerable 
variation in the infant death rate in any locality is almost invariably 
linked with a corresponding change in the diarrheal death rate, the 
mortality from other causes changing, as a rule, comparatively little. 

The factors contributing to infant mortality are so many and varied 



GENERAL STATISTICS 63 

and the difficulties in controlling these harmful influences arc so great 
that at the present day one is forced to admit that, while the prevent- 
able death rate is very large, still among the poor there must neces- 
sarily be a high death rate. 

Bronchopneumonia and true pneumonia also cause not a small 
proportion of deaths during infancy, the majority of fatalities from 
these diseases occurring in the crowded tenement districts. During 
the year 1915 the deaths from these diseases in Philadelphia were as 
follows : 



Cnder oik; year. 


Jan. 


Feb. 


Mar. 


Apr. 


May 


June 


July 


Auk- 


Sept. 


Oct 


Nov. 


Dec. 


Bronchopneumonia . 


59 


37 


53 


.».) 


37 


23 


20 


JS 


15 


30 


27 


58 


True pneumonia 


21 


2(5 


19 


24 


12 


6 


11 


3 


8 


o 


10 


21 


One to two years. 


























Bronchopneumonia . 


](i 


lo 


23 


15 


20 


10 


20 


18 


I.". 


30 


27 


38 


True pneumonia 


10 


11 


19 


21 


13 


7 


4 


2 


1 


4 


7 


12 



Total deaths from bronchopneumonia under one year of age, 432 
Deaths from bronchopneumonia one to two years, 182 
Deaths from true pneumonia under one year of age, 100 
Deaths from true pneumonia one to two years, 111 

Several years ago the mayor of Huddersfield, England, offered a 
gift of $5 to every child born in his town that lived to the age of twelve 
months. All classes, rich and poor, were included; the mortality in the 
Huddersfield district was immediately reduced more than 50 per cent. 

In Yonkers, N. Y., a campaign was undertaken in 1894, having as 
its object the reduction of the infant mortality rate. The physicians 
of Yonkers, aided by the public press, established milk stations, and 
instituted and carried out a campaign of education among mothers. 
A sanitary inspection of the tenement district was adopted, and nurses 
were appointed to visit the sick. The Board of Health also passed a 
regulation requiring in all new tenements a sufficient amount of light 
and air. The deaths from digestive diseases were reduced more than 
50 per cent. Dr. S. E. Getty believes that, of all the means employed, 
the most important was the establishment of the milk dispensaries. 

Holt, in the following table of statistics, shows the decrease in infant 
mortality as the result of a campaign waged in New York City by its 
Board of Health. 

1880 228 deaths per 1000 infants born alive 

1902 168 " 

1908 144 

1911 120 " 

1912 109 

1913 ........ 102 

That a general propaganda against infant mortality has been vigor- 
ously pushed all over the United States is shown by the census, of 1880 
and of 1890. In 1880 the general infant mortality of the United States 
was 246 per thousand; in 1890 it had fallen to 159 per thousand, 
and during the same period it is gratifying to note that the infant 
mortality in cities decreased from 303 to 184 per thousand. In 1914, 
there were reported 204 infant welfare stations in 39 cities and towns 
of the United States. This is surely a record to be proud of. 



64 INFANT MORTALITY 

The Register of Records of the Department of Health in New York 
City shows the reduction in the annual death rate of children under 
five years of age, and this is largely attributed to the use of pasteurized 
milk. The figures are as follows: 



1891 .... 96.5 per 1000 f 125. 1 per 1000 

1901 .... 61.3 " T , , , J 76.2 

1911 .... 43.8 " July aad August 46 _ 3 „ 



1901 .... 61.3 " T , ' J 76.2 

4 o o a July and Augusts 

1913 .... 37.3 " 38 



Since 1910 the deaths among infants under one year of age in 
greater New York have dropped as follows : 

In 1910 16,215 

In 1911 15,053 

In 1912 14,289 

In France, 1874 to 1893, the average infant mortality was 167 per 
thousand. Ten years later, in 1903, it was only 137 per thousand. 
In Paris it was only 101 ; wonderful Paris has the smallest birth rate 
and the lowest death rate of any large European city. 

The physicians of the United States have accomplished much in the 
last ten years, and yet when we consider how remarkably successful 
have been the efforts directed to save infant life, should we not, as the 
representative body of the American profession, feel chagrined that 
we have not accomplished more? Certainly 50 per cent, of all infant 
deaths at the present day are preventable. 

Hospitals for infants have been established all over the w r orld, and 
we are establishing new ones almost daily, and yet some plrysicians 
question whether they do good or harm. Going back to the year 1871, 
we find that 29.82 per cent, of all the children born in Philadelphia 
died before the end of their first year. In the same year, in the found- 
ling ward of the Philadelphia Hospital, 73.65 per cent. died. The 
death rate among the foundlings was 43.83 per cent, more than among 
infants of the same age of Philadelphia. These children were, as a 
rule, in fair health on entering the Hospital. Of these infants, 74.69 
per cent, died from diarrheal diseases, and only 25.31 per cent, from 
all other causes. At this period, the records of the foundlings' ward in 
the Philadelphia Hospital were about the same as the records from the 
foundling hospitals in other large American cities. Dr. A. Jaeobi, 
at this date, had the courage to point out publicly the enormous 
mortality in the foundling institutions of New York, and as a con- 
sequence was asked to resign from the staff of the Hospital with which 
he was connected. 

Van Ingen reports a series of 738 cases of infants in an institution in 
New York City; 22 per cent, of all that died succumbed during the 
first month. The total mortality during the first month among all the 
babies born in the institution was only 8 per cent., but 48 per cent, died 
before the year was ended. 

Dr. Knox, of Baltimore, reports a series of 200 cases of infants in 



GENERAL STATISTICS 05 

different institutions in that city in which 80 to 90 per cent, of the 

deaths occurred before the end of the first year, and this was the actual 
total of those who remained in the institutions. The 10 per cent, that 
survived had practically all been sent away from the institutions into 
the care of foster mothers. 

What is the condition in our infant hospitals at the present day? 
My personal opinion is that in the modern infant hospital, where 
the air space is ample, and the windows are kept open day and night; 
where the milk is the best and the milk-room thoroughly up to date; 
where the ratio of nurses to patients is not less than one to five; where 
the sick are promptly isolated from the well, and "mothering" is 
understood — that in such a hospital the physician is an optimist and 
not a pessimist. 

Many of the infants will die, but most of them will live. If one 
considers that many of those who die are "weaklings" on admission, 
and that the greatest proportion of deaths occurs in the first three 
months of life, one is apt to believe that the best of the modern infant 
hospitals are worthy institutions and should be supported. Much 
depends on the character of the feeding; but, here as ever, the truth 
that breast feeding is better than bottle feeding is well exemplified. 

Of 300 infants admitted to the Dresden Children's Polyclinic in 
1900 to 1901 there were 53 deaths. All the deaths, 53 in number, were 
among the bottle-fed babies. Among 93 breast-fed babies, during the 
same period, in the same hospital, there was not a death. Breast- 
feeding is surely a powerful measure with which to combat death. 

According to the census of 1900, the infant mortality per 1000 in 
the United States was in those States where registration was in force: 

Per L0O0 hirths. 

District of Columbia 274.5 

Rhode Island 197.9 

Massachusetts . . • 177. 8 

New York 159.8 

Connecticut 156.8 

Maine 144 . 1 

New Hampshire 172.0 

New Jersey 107.4 

Vermont 122.1 

Michigan 121.3 

The census of 1900 shows the returns for infant mortality from many 
cities and towns of the United States. The infant mortality in some 
of these cities is very high, over 400 per 1000 in Charleston, S. C. 
A number of them show a mortality above 300, and more than 100 
cities exhibited an infant mortality above 175 per 1000. 

The important point to be decided is as to the influence which has 
been exerted on this infant death rate in recent years. Have we been 
able to reduce in any appreciable degree this great and unnecessary 
waste of infant life? A careful study will show that there has recently 
been a great saving of life, and much will surely be accomplished in 
the future. 
5 



00 INFANT MORTALITY 

In 1903 the infant mortality' of France was 137. In the previous 
twenty years it was 107, and yet this death rate ought to be still more 
greatly reduced, for we know that Ireland has an infant death rate 
below 100. Norway in 1902 had an infant death rate of 75, and 
Sweden 107 per 1000. 

Of all European countries, Russia has the highest infant death rate, 
270 per 1000. Germany has the next highest, averging in recent years 
a little over 200 per 1000. Medical science and skill have reached 
a very high plane in both these countries, and infant mortality has 
been greatly reduced during the last thirty years. It is to be hoped that 
the useless waste of life in these two countries will quickly be much 
more distinctly diminished, and it is believed they will soon show as 
great a reduction as has been brought about in France. 

There has been a great decrease in the proportion of infants d}'ing 
under one year of age in the United States during the last twenty years. 
The infant mortality in 1880 was 246 per 1000; in 1890 it had fallen 
to 159 per 1000. During the same period the mortality in the cities 
of the United States fell from 303 to 184 per 1000. 

Many figures might be quoted showing that in recent years infant 
mortality has distinctly lessened. In London in January, 1908, the 
deaths of infants under one year of age to 1000 births was 115. Accord- 
ing to George B. Mangold, U. S. Department of Commerce and 
Labor, the infant mortality in New York City in 1891 was 241.9 
per 1000; in 1900 it was 191.7 per 1000; and in 1906 it was 167.8 
per 1000. In the same city the death rate of children under five years 
of age was 96 per 1000 in 1891 ; in 1896 it had fallen to 77.5 per 1000, 
in 1900 the mortality under five years of age was only 67 per 1000; 
and in 1904, it was 54 per 1000. In the same community the deaths 
from measles, scarlet fever and diphtheria have become distinctly 
less; and diarrheal diseases in small children have decreased 62 per 
cent, since 1881. 

School nurses are now provided and medical inspection of schools 
is today well recognized and practised in many of our large cities. 
According to Dr. W. M. L. Coplin: "A necessity for medical attention 
was detected in 27,481 children in the schools of Philadelphia in 1905, 
and 31,544 children in 1906." Dr. A. C. Abbott, formerly chief of 
the Bureau of Health of Philadelphia, shows that in the years 1903-5 
a distinct decrease in the infant death rate occurred. Philadelphia 
shows a very decided decrease in infant mortality since 1897. 

Thomas A. Buckland, City Chemist for St. Louis, states that there 
has been a decrease in infantile mortality in that city since 1904. 
W. Ernest Wende, M.D., Health Commissioner of Buffalo, states that 
infant mortality is decreasing in that city. Samuel E. Allen, Health 
Officer of Cincinnati, states the proportion of deaths of children under 
two years of age to the total mortality has decreased considerably 
since 1886. In the year 1886 it was 32.56 per cent.; in the year 1906 
it had decreased to 21.92 per cent. 

Milwaukee and Minneapolis and the nine largest cities in the State 



GENERAL STATISTICS 07 

of New York, according to George W. Goler, M.D., show a decrease 
in infant mortality: 

The following have occurred to me as being important factors 
in lessening infant mortality: 

Abatement of nuisances. 

Milk inspection: milk dispensaries; visiting nurses. 

Free antitoxin. 

Improved sanitation. 

Good food. 

Education of girls and married women in the duties and requirements 
of motherhood. 

Maternity fund in all industrial establishments where married 
women are employed. 

Care of poor pregnant women before and after confinement. 

Laws carefully protecting all children who are cared for by private 
individuals, apart from their parents; rigid enforcement of these 
laws. 

Elementary principles of hygiene taught in all schools, public and 
private. 

Nursing of all babies, as far as possible, by their mothers. 

Sending children to the country in summer. 

Pasteurization of milk during the hot months. 

Farming out, under proper medical supervision, of foundlings and 
institution infants, and the appointment of nurses to visit these infants 
regularly. 



CHAPTER V. 
HEREDITY. 

We derive certain characters from our parents, and certain characters 
from our progenitors other than our parents. The entire body is, 
as it were, built up of myriads of units, each unit inherited from some 
ancestor. It is important to remember that the child inherits not only 
certain physical characters; as height, features, color of eyes, etc., but 
that mental and moral characters are also inherited, such as moral sense, 
ambition, industry, activity; and there is strong evidence to prove that 
a trait or fundamental principle absent in both parents cannot be 
present in their child, also that some defect that is marked in both 
parents, especially if there is consanguinity of the parents, is apt to be 
present in their children. For instance, it has been estimated that 
almost one-third of the children of deaf-mutes, if there is consanguinity 
in the parents, are deaf, whereas only one-tenth of the children of such 
parents are deaf when the parents are not blood relatives. Deafness 
may arise from a great many causes, and the possibility of this 
cause being found in both parents is much more likely if they are 
consanguineous. 

The inheritance of one mental or physical property does not depend 
upon the inheritance of others; for instance, one child in a family 
may have straight hair, another curly hair, while both may have 
blue eyes. In fact, when the parents and grandparents are known, 
many physical characteristics of the children may be explained. An 
inherited condition — for instance, hemophilia — may be transmitted by 
an apparently normal person. 

Man begins as a single cell, the fertilized ovum, and the organism 
is built up by cell division. As evolution proceeds environment 
assists in producing certain changes; i. e., certain characters, which 
may formerly have been essential, have, owing to changes in environ- 
ment, become less useful or, in fact, only a hindrance, and these 
characters which are no longer of any use or assistance tend to disap- 
pear. As development progresses the environment, if it is to suit 
accurately the new individual, must also change. 

The embryo of man shows at a certain stage of its embryonic life 
an arrangement quite analogous, as far as the large bloodvessels are 
concerned, to that found in the gills of fish. This would tend to 
indicate that the progenitors of man were more or less aquatic animals ; 
but, the human embryo not needing any apparatus similar to the 
gills of fish, these have disappeared except for such scant evidences of 
their former existence as the branchial clefts and arches. Changes of 
this type, called regressive, are of course brought about only slowly, 



HEREDITY 69 

and are in marked contrast to other characteristics spoken of as 
progressive, which arc in keeping with the evolution of the individual 
and its changed environment. By this method of regressive and 
progressive changes which take place in all of the organs and tissues 
of the body the gradual development of the higher animals occur-. 

Children may, and not uncommonly do, show mental and physical 
traits which were not present in either parent, but were inherited from 
some ancestor. All that environment can do is to modify the inborn 
characters. Environment and training are certainly the direct causes 
of acquired characters in the individual, and, if the same environment 
persists, these characters may appear in the offspring. If, however, 
the special environment that has brought about the acquired character 
is not present, the acquired character usually ceases to reappear in 
the offspring. Characters disappear sooner or later when they cease 
to be the subject of selection. Variations occur in all directions, and 
it is the environment which is influential. If the transmission of 
acquired characters has played an important part in evolution it has 
come about by the selection of inborn variations. 

Acquired characters may be transmitted, but it is not a common 
or usual occurrence; the evidence or proof that acquired characters 
are frequently inherited is insufficient ; but as most competent observers 
attach a certain amount of weight to this idea, it may be accepted 
tentatively as an occasional fact, and its acceptance and belief may do 
good by stimulating the better side of our natures. Undoubtedly 
acquired characters are, as a rule, simply normal variations and the 
natural transmission of such variations; if suited to the individual's 
environment, they are permanent and progressive; if not adapted to 
the environment they are more or less rapidly eliminated. In order 
to believe that the inheritance of acquired characters is common or 
usual, one must also believe that it is possible for this acquired char- 
acter to exert some specific and definite action on the germ cell itself, 
and it is certainly improbable that some characters, developed perhaps 
in middle adult life, could produce this effect. 

Environment can only modify characters; it can not originate 
them; and it is self-evident that each specie is in the environment 
best adapted to its development. Use will develop both mind and 
body, and environment is certainly the cause of acquired characters 
developing or appearing in an individual, but environment rarely, if 
ever, produces changes in the inborn characters. 

It is important to appreciate that diseases in the parent, such as 
syphilis, rheumatism, or acute alcoholism, do produce mental and 
physical diseases in the offspring; but the diseased condition or taint 
or inherent weakness is in these cases transmitted directly to the 
germ cell, and normal heredity differs from diseased heredity as normal 
tissue differs from diseased tissue. If this diseased offspring is not 
placed under the best environment and given proper medical treatment 
it tends to be eliminated, and disappears either in the first or succeed- 
ing generations. If the environment and treatment are proper and 



70 HEREDITY 

suitable 4 , it may in the first or later generation return to the normal 
standard of its progenitors. Heredity is constructive, not destructive; 
it tends to build up, not to tear down; and will, if assisted, always 
do its full share toward restoring the individual to the normal for 
its species. 

Variations are not always of the same kind or type, and the persist- 
ence or disappearance of these variations depends on the environment. 
The descendants tend to inherit these variations, some in a greater, 
others in a less degree, and with changing environment and selection 
certain new characters, as sight and hearing, are evolved. Variations 
are of common occurrence, but need environment to complete the 
process of evolution. As environment changes, the species must 
change, else it would be destroyed. 

The effect produced by environment is clearly shown by the well- 
known experiments of Xageli. He removed some Alpine plants from 
their usual location and transplanted them to the rich and fertile soil 
of the Botanical Gardens in Munich. Under the new environment the 
plants and foliage became much more luxuriant, and the seeds from 
these plants also produced this new and abundant growth. After 
thirteen years of such cultivation and luxuriant growth the plants 
differed greatly from their original stunted and sparse forms. When, 
however, these plants were removed back to the original poor soil 
of their Alpine environment, they quickly lost all their acquired 
luxuriance of foliage and growth, and returned to their former stunted 
and dwarfed condition. This experiment adds much weight to the 
theory that acquired characters can and often will be inherited if the 
offspring be placed in the same conditions of environment as the 
parents were living in when the change in their characters occurred; 
and while it tends to show that these acquired characters can undoubt- 
edly be caused by environment and can be transmitted, still, there 
was no permanency to these acquired characters except while the 
changed environment persisted. 

It is well known that the cells of the central nervous system do not 
multiply after birth; they of course develop, and gradually assume 
certain functions; but no new nerve cells are produced, and, once 
destroyed, they are never reproduced. Evolution in the higher 
animals as seen in man means an increase in the size of the brain 
and a consequent increase in the intelligence; but we have as yet no 
proof of the possibility of parents being able by acquiring brain cells 
to transmit any added number of brain cells to their offspring. The 
difference between man and the higher apes is especially noticeable 
in the brain, and all records of man show that he has not changed any 
in brain capacity. 

In the consideration of the characters inherited from our immediate 
parents and progenitors, it is of course true that changes in environ- 
ment accomplish much, and that characters acquired by the parents 
may appear in the offspring, during many or all succeeding generations, 
if the offspring live under the same conditions as the parents, and 



HEREDITY 71 

the environment (Iocs not change. But it is, nevertheless, true that 
man lias changed very little, if any, in stature and brain capacity 
during the past 5000 years. As far back as the reindeer age, skeletons 
of men and women show height and brain capacity to have been about 
the same as in the highest types of man today, and the skulls show 
no changes in the jaw or frontal bones. The eharaeters of a race 
undoubtedly change very little from generation to generation; in- 
dividuals differ sufficiently in looks, voice, external appearance and 
temperament to be recognized and grouped, and these slight variations 
always occur in races. 

The individual inherits one-half of his characters from the two 
parents, one-fourth from the four grand-parents, one-eighth from the 
great-grandparents, one-sixteenth from the great-great-grandparents, 
and so on. This is true not so much in an individual case a> when large 
numbers of individuals are observed in the aggregate. 

Galton traced the family histories of parents of unusual mental 
capacity, and proved conclusively that these superior and unusual 
mental characters were inherited, and the offspring of such parents 
were superior mentally to the offspring of parents mentally inferior. 
Parents with unusual mental powers will transmit such powers to 
their offspring, even if the mental powers of the parents have not been 
developed by educational methods and environment — hence the mental 
powers of a child are largely decided before he is born. This does not 
imply that the individual's mental powers may not be improved by 
education and environment; but the mental powers of the child will 
be the same whether the parents were educated or not. The hope of 
improving the race by giving special care to the weak and feeble- 
minded is fallacious, and marriage and procreation by such parents 
can only tend to lower the general tone of the race. 

Heredity has been defined as "the inheriting of certain qualities or 
tendencies, or the tendency manifested by an organism to develop 
in the likeness of its progenitors." 

"Degeneracy is the absence or loss of that degree of development or 
energy seen in the ancestry of the organism." Heredity is a tendency 
to develop the type of the ancestor. Degeneracy is a tendency to a 
lower type than the ancestor. All evolution results from variation and 
heredity. If type a is to become b by evolution, some individuals of 
a must vary toward 6, and this variation must be inherited and trans- 
mitted until a finally becomes /;. The ovum and spermatozoon must 
bear in themselves all the characters that are inherited from their 
parents and ancestors. 

Environment is a potent cause in the production of variations. 
Heredity should and does imply merely a single link in a long chain. 
Degeneracy may be inherited or it may be acquired; it is a mere 
accident in a long line of heredity. 



CHAPTER VI. 
CONGENITAL MALFORMATIONS. 

BRAIN AND SPINAL CORD. 

Meningocele, cephalocele, and hydrencephalocele are hernise of 
certain portions of the cranial contents, either through an abnormal 
opening in the bony skull or along one of the lines of suture or fissures. 
The openings through which the cranial contents protrude are found in 
the occipital, nasal, parietal, and temporal regions. 

Etiology. — The etiology is rather obscure. Hornke and Hertwig 
produced similar deformities in some animals by chronic poisoning of 
the parents before impregnation, and in others by injuring the ovum. 
Von Bergmann claims that a misturning of the cerebral sac is the 
important factor in its causation. 

Pathological Anatomy. — The opening in the skull is usually small, 
and the dura mater does not protrude, only the arachnoid and pia 
mater escaping from the cranial cavity. The membranes are often 
greatly thinned by the distention of the contained fluid. Small tumors 
are the more common, and are less apt to contain brain tissue. 

Meningocele. — A meningocele contains the internal membranes of 
the brain, and these membranes are usually, but not invariably, 
distended with fluid. The opening into the brain is generally small. 
Fluctuation is present in the tumor, but not pulsation. 

Symptoms. — Bimanual palpation, one hand on the tumor, the other 
on the fontanelle, will disclose increased tension in the fontanelle, 
unless the opening into the cranial cavity has become occluded. If 
the sac does not rupture, and is not of large size, a meningocele may 
produce few, if any, symptoms. If, however, it becomes progressively 
larger and the walls thinner, the nutrition of the enveloping skin and 
scalp tissue becomes impaired, and infection and bursting become 
more likely. 

Diagnosis. — The diagnosis is usually easy. The location of the tumor 
is significant; its partial reduction by pressure and fluctuation, if 
present, help to confirm the diagnosis. If, in addition to this, there 
is pulsation and pedunculation the diagnosis is rendered practically 
certain. 

Treatment. — Surgery offers the only hope for the patient. This 
consists in the removal of any fluid the tumor may contain, and the 
closure of the hernial opening. It must be borne in mind that young 
children stand long operations badly. If hydrocephalus is present, 
the result is apt to be unfavorable. If the tumor is small, this adds 
to the probable success of the operation. As a rule, the result of the 




Fig. 2. — Meningocele in a child aged four months. 




Fn;. 3. — Meningocele. 




Fir;. 4. — Meningocele, child aged seven months. 



74 



CONGENITAL MALFORMATIONS 



operation in meningocele is much more favorable than in eneephalocele 
or hydrencephalocele. 

Eneephalocele. — This consists of not only the membranes of the 
brain but also of brain tissue. The tumor does not connect with 
any of the ventricles, and, if fluid is present, it is in the outer portion 
of the sac, immediately beneath the skin and underlying tissues. The 
opening into the skull is usually larger than in a meningocele, and the 
tumor is generally small and not pedunculated as in a meningocele. 
Pulsation is often present, and the tumor is with difficulty reduced by 
pressure; cerebral symptoms commonly follow efforts at reduction. 

Treatment. — The treatment is entirely surgical. The smaller the 
tumor the better is the prognosis; although, as surgery presents the 
only hope, the child should be given the chance for its life that surgery 
offers. Much depends on the child's physical condition, the mainte- 
nance of all its vital forces, and on the care of a skilled pediatrician, 
as well as upon the surgical technic employed. Unless such combined 
care is possible, surgical interference is useless. 




Fig. 5. — Eneephalocele. child three days old. 



Hydrencephalocele. — This consists of a portion of brain tissue 
enclosing a cavity filled with fluid which communicates with a 
lateral ventricle, the entire mass being covered externally with brain 
membranes. The tumor can not be reduced, is usually of large size,, 
and is apt to be pedunculated. The fluid in this form is in the interior 
of the mass, and gives a sense of deeper fluctuation than in the other 
two forms; moreover, this form may be associated with hydrocephalus. 
It is the most serious of all brain hernise, and offers no hope of cure by 
surgical means. The diagnosis of this variety from meningocele and 
eneephalocele is important, as operation offers some hope in the last 
two conditions. 

Acute Hydrocephalus. — Acute hydrocephalus is associated with 
inflammation of the base of the brain, and is, as a rule, tubercular. 



BRM\ AND SPINAL CORD 75 

An increase of fluid is always found in acute meningitis of all forms, 
hut the quantity of effusion into the ventricles is usually small. As a 
consequence of the small amount of effusion in acute hydrocephalus, 
associated as it is with meningitis, the head rarely attains any great 
size. It is usually the result of tuberculous meningitis, is the most 
common form of brain inflammation seen in children, and is almost 
invariably fatal. Tuberculous meningitis will be found described in 
full under "Diseases of the Nervous System." 

Chronic External Hydrocephalus. — Chronic external hydrocephalus 
is rare as compared with the internal form. It may be the result 
of hemorrhage of the meninges, pachymeningitis, or congenital mal- 
development of the brain, the latter cause producing the most typical 
cases. The convolutions are flattened and atrophied from the pressure 
of the fluid situated outside of the brain substance between the dura 
and arachnoid. If present in large and increasing quantities the fluid 
may cause a progressive enlargement of the head, similar to that seen 
in the internal variety of the disease; usually, however, the amount 
of fluid is small, and the distention and pressure only slight. 




Fig. 6. — Chronic internal hydrocephalus, child a<red seven months. 

Chronic Internal Hydrocephalus. — Congenital hydrocephalus is 
almost always of the internal variety. In this form the lateral ventricles 
are distended with fluid, the brain substance being stretched and thin 
because of the great pressure. The fontanelles are much increased 
in size as the result of a large amount of contained fluid, and the 
bones of the head are more or less forced apart. 

Etiology. — Evidences of hydrocephalus may be present to a marked 
degree at birth, but more often they are only slight, if present at all, 
and commonly the infant does not show any manifestations of the 
disease until it is some weeks of age. Among the systemic causes 
capable of producing the disease may be mentioned alcoholism, 
syphilis, heredity, and trauma during pregnancy. Among the local 
causes are meningitis, disease of the choroid plexus, leptomeningitis, 
the pressure of brain tumor, and obliteration of the foramen of 
Magendie. The disease may be congenital or acquired. In a certain 
proportion of cases hydrocephalus will be found associated with rickets, 
and in my experience these cases are the most hopeful. Cases have 



/ (> ( 'ONGEN I TA L MA LFO RMA TIONS 

been reported where the hydrocephalus has followed a successful 
operation for spina bifida or encephalocele. The salt content of the 
cerebrospinal fluid is very low and is of the natrium variety. The 
protein elements in the fluid are also very low. 

Pathological Anatomy. — The brain shows an accumulation of fluid 
in the ventricles and the septum lucidum partly destroyed by pressure. 
The brain is anemic, and it may be difficult to differentiate between 
the gray and the white matter. The ependyma is generally thickened 
and anemic. Other congenital deformities may also be present. A 
chronic meningitis, usually basilar in type, may be found, and the 
choroid plexus may show inflammatory changes. The foramen of 
Magendie may be obliterated, and a brain tumor may be present. 
The specific gravity of the fluid varies from 1005 to 1007. 

Symptoms. — The most noticeable symptom is the large size of the 
head, which may be so large as to cause the death of the child during 
its birth. The forehead is bulging, the anterior fontanelle widely dis- 
tended, and the frontal and parietal bones are often greatly separated. 
The anterior fontanelle is tense and bulging, the eyes protrude, and 
the cornea is partly covered by the lower eyelid, the white sclera show- 
ing above. The skin covering the bones of the head is stretched, and 
the superficial veins dilated. The head is wedge-shaped, the apex 
being formed by the chin. The eyes have a downward direction as the 
result of pressure upon the orbital plates of the frontal bone, and 
nystagmus and strabismus may occur. The hair is scanty and dry, 
and there is often inability to hold the head erect. The mental powers 
are usually more or less deficient, although if the fluid accumulates 
slowly a fair degree of mentality may be present. xAtrophy of the 
optic nerves was observed in a few of my cases but, as a rule, only in 
those in whom the pressure was extreme. The arms and legs may be 
more or less rigid, and the hands tightly closed;. or the extremities 
may be relaxed and flaccid. The reflexes are usually exaggerated. 
The pupils are, as a rule, equal and are more apt to be contracted than 
dilated. Convulsions occur in a fair proportion of cases. A slight 
increase in the hydrocephalic fluid very often produces marked symp- 
toms, providing the bones of the cranial vault are firmly ossified; 
whereas, in certain cases, if the anterior fontanelle, frontal, and 
parietal sutures are still more or less membranous, the bony walls 
are somewhat elastic, and the symptoms may be very slight. 

Diagnosis. — It has been demonstrated by Theobold Smith, Arthur 
I. Kendall, and many others that there is an available carbohydrate 
in the normal cerebrospinal fluid that directly influences the activity 
of the bacteria. Toxins are not produced in the cerebrospinal fluid 
in the presence of this carbohydrate, and the carbohydrate that the 
normal cerebrospinal fluid contains is generally believed to be a form 
of non-fermentable dextrose. This carbohydrate of the normal 
cerebrospinal fluid is the first element attacked by the bacteria after 
their entrance into the central nervous svstem. The flora which 



BRAIN AND SPINAL CO HI) il 

ordinarily is represented by the infectious agent belongs to the group 
which prefers a carbohydrate to a protein diet. The first proof, 
therefore, of pathogenic microbic invasion is found by the absence 
of this copper-reducing body from the cerebrospinal fluid. This is 
practically true in all forms of brain inflammation except in the 
tuberculous variety of slow development. A copper-reducing body 
is absent from the cerebrospinal fluid in other forms of meningitis. 
This finding antedates by some hours, and possibly by a. longer period 
than this, the demonstration of bacteria in the fluid. It is, therefore, 
of assistance in diagnosing the presence of a meningitis in its very 
earliest stages. Moreover, if the hydrocephalus is due to a previously 
existing meningitis, the reappearance of the copper-reducing body 
after its earlier disappearance is evidence of the subsidence of the 
meningitis and consequent improvement in the prognosis. In a fair 
proportion of cases hydrocephalus seems to be the result of a chronic 
inflammation of the ependyma. 

A rachitic head is about the only condition which resembles hydro- 
cephalus. In rachitis the head is square, and the vault is more flat 
than in hydrocephalus, where it is apt to be rounded. The rachitic 
head does not show bulging fontanelles; moreover, other evidences of 
rickets are usually found in the bones of the chest or extremities. 
Systematic head measurements will, if the case is hydrocephalus, 
generally show a gradual increase in its circumference. 

Prognosis. — The child usually becomes progressively weaker, suffers 
from headache, vomiting, and may possibly have convulsions. Death 
in the large majority of cases results from some intercurrent disease. 
The child may die as early as the sixth month, and it rarely lives to 
be more than seven or eight years of age. Cure has apparently 
taken place in a few cases by spontaneous evacuation through a 
fissure into the nasal cavity. Permanent drainage of the lateral 
ventricles seems to offer the best prospect of cure in well-marked 
chronic cases. 

The prognosis as to life depends largely upon the rapidity with which 
the fluid accumulates. In those cases in which the fluid rapidly 
increases in amount, death may occur at six months or one year with 
all the symptoms of hydrocephalus present in severe form. If, 
however, the fluid accumulates very slowly, there may be few, if any, 
symptoms and the prognosis as to life is much better, the child living 
to be six or eight years of age. Few cases that show a progressive 
enlargement of the head live beyond this period. If the fluid ceases 
to accumulate at any age life may be indefinitely prolonged, the child 
being usually more or less mentally and physically defective. 

Treatment. — In some of my cases in infants a cure has resulted 
when hydrocephalus has been associated with rachitis, and after one 
or more lumbar punctures the infant has remained perfectly well. 
At least three such cases have now continued to be well for periods 
varying from two to three years. Lumbar puncture has often in my 



78 CONGENITAL MALFORMATIONS 

experience caused a marked temporary lessening in the symptoms, 
especially headache and vomiting. Many other operations have 
been devised; fine drains or a silver tube have been placed between 
the subarachnoid space and ventricles. This is practically autodrain- 
age, and out of a number of cases operated upon some have shown 
marked improvement. The operation of puncturing > the corpus 
callosum has been employed, with the object of relieving brain pressure 
by establishing an opening between the ventricles and subdural space 
of the brain cord. Some excellent results are reported to have followed 
this operation. Permanent drainage seems to offer the greatest hope 
for the permanent cure of this condition. Treatment by drainage of the 
cisterna magna, as recommended by Kopetzky and Haines, especially 
for meningitis, is of course applicable to cases of hydrocephalus. 
Better results from operation are obtained in those cases where the 
accumulation of fluid is very slight than in those where it increases 
rapidly in quantity. If there is even a vague suspicion of syphilis 
being the cause of the condition, the child should be given a thorough 
course of iodide of potassium and mercury by inunction. Fresh air, 
proper food, and the best hygienic surroundings possible assist in 
keeping up the general health and nutrition. 

Caput Succedaneum. — The most common malformation is the 
swelling of that portion of the head which represents the presenting 
part. It consists of an effusion into the soft tissues of the scalp outside 
the periosteum. It is rarely seen following a rapid or easy labor, but 
the more tedious and prolonged the labor the more marked, as a rule, 
is the caput succedaneum. Its most common location is on one of the 
parietal bones extending backward to the occiput. The effusion is 
absorbed spontaneously, and requires no treatment. Care should be 
taken carefully to cleanse the portion of scalp tissue overlying the 
swelling, and to protect this portion from any infection which might 
follow slight trauma of the scalp occurring during labor. 

Cephalhematoma. — Cephalhematoma is a tumor filled with blood, 
produced by a rupture either before birth or during labor of some of 
the vessels of the cranial periosteum. It is most often found over 
one of the parietal bones, and is usually spontaneously absorbed. 
It is commonly found outside of the skull, although it is occasionally 
situated inside the cranium. The variety outside of the skull is called 
external, and the form within internal; the external is by far the more 
common. In the external variety the blood is between the periosteum 
and the skull, or between the periosteum and the occipitofrontalis 
muscle; in the internal form the extravasation takes place between 
the dura mater and the skull. 

Etiology. — A common cause of cephalhematoma is difficult and pro- 
longed labor, and it may also follow the application of the forceps. 
It is most common in vertex presentations, although occasionally 
observed in breech cases. Poorly developed bloodvessels and abnormal 
conditions of the blood in infants are predisposing causes. Another 
predisposing cause is a weakened or badly nourished state in the mother. 



BRAIN AND SPINAL CORD 



79 



While it is true that difficult labor and the application of the 
forceps have much to do with the formation of cephalhematomata, 
still the factors of bloodvessels, blood, and nutrition are also operative. 
In proof of this may be mentioned the fact that cephalhematoma 
has been recorded in infants delivered by Cesarean section and also 
in prematurely born, hence small infants. It is present in about one 
and a half per cent, of all cases. 

Pathology. — It is commonly found over one of the parietal bones, 
its position usually depending upon the portion of the head that 
presents, although breech presentations may show the tumor in the 
occipital region. One, two, or three tumors may be found in the same 
patient. As the hemorrhage is from the periosteum the swelling, on 




Fig. 



-Double cephalhematoma in an albino, aged three weeks. 



account of the close attachment of the periosteum at the sutures, is 
always limited to the area represented by the bone. Slight hemor- 
rhage occurs in the scalp. Beneath the cephalhematoma is felt a 
crater-like opening which upon pressure at the external border gives 
a sensation of crackling, this crepitus evidently resulting from pressure 
upon the bony cells and the thin blood-clots which rapidly develop 
along the edges of the tumor; that is, at the line of separation of the 
periosteum. In cases of cephalhematoma complicating severe injury 
to the head, trauma of the soft parts, or depressed fractures, infection 
may be present, and possibly meningitis. The tumor usually entirely 
disappears in from five weeks to three months, and the smaller the 
mass the more rapidly, as a rule, it is absorbed. After its absorption, 



<S() CONGENITAL MALFORMATIONS 

a firm irregular thickening usually remains for a considerable length 
of time at the site of the tumor. 

Symptoms. — A cephalhematoma usually appears during the first 
five days of life, and gradually increases in size for a period of from 
six to ten days, then tends to become smaller. It may vary in size 
from the smallest swelling to one as large as a goose egg. Fluctuation 
is present, but the mass can not be reduced in size by pressure, since 
no portion of it can be returned within the skull. Violent crying 
produces no effect on its dimensions or tenseness, and it is soft and 
elastic to the touch. Unless infection has occurred, there are no local 
or constant signs of inflammation, and pulsation is very rarely present. 

Diagnosis. — Cephalhematoma may be diagnosed from hernise 
cerebri by the fact that the latter always occur along one of the suture 
lines, at a f ontanelle, or at some opening in the skull ; whereas cephal- 
hematoma beginning beneath the periosteum is always limited to 
the area of the bone. Meningocele and encephalocele are partially 
reducible, and symptoms of cerebral pressure commonly follow efforts 
at reduction; in addition to this, crying may increase their size. None 
of these conditions, of course, prevails in cephalhematoma. A 
depressed fracture does not show a tumor above the normal cranial 
vault as does a cephalhematoma, and the ridge that surrounds a 
cephalhematoma is elevated above the level of the surrounding bone, 
and has a crater-like center; caput succedaneum is not limited by 
sutures, and is rapidly absorbed within a few days; moreover, it is 
usually present at birth, while cephalhematoma generally develops 
after birth. If it is absolutely necessary to verify the diagnosis of 
cephalhematoma, an aspiration needle may be inserted into the 
tumor, and the presence of pure blood be demonstrated, but this punc- 
ture, must be performed only under the most rigid rules of antisepsis. 

Prognosis. — The prognosis is favorable, absorption usually taking 
place in from six weeks to three months. If a large hematoma has 
formed within the skull, it may, unless rapidly absorbed, produce 
pressure symptoms and lesions. 

Treatment. — Uncomplicated cases require, as a rule, neither local 
nor constitutional treatment. Care must be exercised that the tumor 
be not injured by pressure or manipulation, and that the scalp is kept 
clean and free from possible infection. Any local injury or infection 
of the soft parts, bones, brain membranes, or brain substance would 
necessitate appropriate surgical treatment. An internal cephalhema- 
toma producing symptoms which persist calls for surgical interference. 
Under strict antisepsis a small incision may be made in the scalp, 
the sac opened, the blood expressed, and an antiseptic pad firmly 
applied. This has the advantage of securing the immediate removal 
of the blood, and prevents the thickening that may persist after 
absorption without operation. 

Anencephalia. — Anencephalia means, literally, absence of brain; 
and the monsters to whose condition this term is applied are born 
with the vault of the cranium missing, owing, it is believed, to the 



BRAIN AND SPINAL CORD 



81 



production of an abnormally sharp cranial flexure in the embryo. 
Usually a reddish, fleshy mass, which may contain rudimentary brain 




Fig. 8. — Anencephalia. 




Fig. 9. — Anencephalia. 

tissue, is found lying upon the basal bones. In very rare cases there 
is no brain tissue whatsoever (Figs. 8 and 9). 
6 



82 



CONGENITAL MALFORMATIONS 



These fetuses are usually of the female sex. Their bodies are well- 
developed. The head appears to sink down between the well-formed 
shoulders, while the face is turned upward; the eyes are protruding. 
The base of the skull is narrow, the nose broad and flat, and the mouth 
is held partly open, which gives the monster a toad-like appearance. 

During the last few weeks of pregnancy the pressure of the anen- 
cephalic head not infrequently causes extreme irritability of the 
bladder in the mother, and at delivery the broad shoulders may 
render podalic version necessary. The face usually presents. 

These monsters rarely go on to full term. They are not extremely 
rare, and most physicians with a large obstetric practice can recall 
at least one case within their own experience. Formerly several 
classes of these monsters were recognized; but today they are all 
included in the term anencephalia. 




Fig. 10. — Hare-lip and cleft palate in a infant five months old. 



HARE-LIP AND CLEFT PALATE. 

Hare-lip. — It is a well-known anatomical fact that congenital 
malformations of this type are physiological at one period in the 
development of the fetus, and are the remains of fissures that are 
primitive and naturally present in the normal infant at a certain stage 
of the process of development. 

Etiology. — Many theories have been advanced as to the causation 
of these conditions. Alcoholism in the parents, producing a lack of 
developmental power in the fetus, is a probable cause, this lack being 
either mechanical or pathological. Heredity' undoubtedly plays an 
important role, and is by many considered a most important factor. 
An increase of intracranial pressure, adhesions, deficient amniotic 
fluid, and amniotic bands, are also probable causes. A failure of the 
globular processes to join will also produce a fissure in the upper lip. 
The second upper maxillary processes uniting with the anterior margins 
of the head fold form later the upper maxillary bone, and a portion of 



HARE l.ll' AND CLEFT PALATE 



83 



the head fold also assists in the formation of the nose and intermaxillary 
hone. The failure of any of these structures to develop properly, or 
the laek of proper union of these different structures, will cause the 
congenital malformation of hare-lip. 

Pathological Anatomy. — The fissure may be of the lip only, and either 
one or both sides may be involved. The deeper soft parts, that is, 
the upper maxillary processes, may or may not be involved, and the 
palate may be normal or cleft. It may extend into the nose, or may be 
merely the slightest drawing in of the lip. The fissure is rarely if ever 
in the median line, and the cleft may be large or small. Either single 
or double hare-lip may be associated with cleft palate, although double 
hare-lip with cleft palate is the more common. 
The fissure is situated either between the canine 
tooth and the second incisor, or between the 
first and second incisors. The altered position of 
the intermaxillary bone may cause the teeth to 
develop at a right angle to the. fissure, or the 
teeth may be directed almost straight outward. 

Symptoms. — These infants often have great 
difficulty in nursing, as it is frequently almost 
impossible for them to produce a partial vacuum 
in the mouth, hence they are unable to cause the 
milk to flow from the nipple; moreover, the milk 
is hard to swallow as it tends to regurgitate 
through the fissure in the lip. Pumping the 
breasts and feeding with a Breck feeder (Fig. 
11) or a spoon is often resorted to. Every effort 
should be made to preserve the mother's milk, 
as it is important for the child to be kept as 
well-nourished as possible. All cases, of course, 
breathe largely through the mouth, which predis- 
poses them to disease of the respiratory tract. 
Gastro-intestinal disturbances and bronchopneu- 
monia have also in my experience been among 
the most common complications met with in the 
postoperative medical treatment. 

Prognosis. — The disfigurement associated with a hare-lip is so marked 
that almost all parents, even the most ignorant, will give their consent 
to an operation. The risk of the infant's losing its life is not great, 
the mortality of the operation being only about 3 per cent, or less. 

Treatment. — Long before the days of antiseptic surgery, hare-lip was 
a common condition upon which to operate; the dangers of the opera- 
tion are hemorrhage, infection which is traumatic in character, and 
shock, the latter especially in a frail young infant. The time when 
the infant should be operated upon depends upon the general physical 
condition and vitality. Tien 1 , as in all other conditions in children, 
the vitality is in proportion to the weight, general physical develop- 
ment, and constitution. The age of the child is less important, as 




;. 11. — The Breck 
feeder. (Kirley.) 



84 



CONGENITAL MALFORMATIONS 



regards the time of operation, than its physical condition. A vigorous 
child two months of age may be operated upon; a delicate infant of 
two months should, if possible, be built up physically, and perhaps 
not be operated upon until it is six months old. Before operating the 
child should be carefully examined for other congenital malformations, 
especially of the heart, which, i£ present, would naturally necessitate 
the postponement of operative measures. Nasal catarrh and bronchitis 
should be cured by appropriate treatment before operation, and 
surgeons should insist on the child's feeding and nutrition being 
looked after before and after operation by a skilled pediatrician. 
Secondary operations should be deferred for at least a few months. 
For details as regards the operation surgical treatises should be 
consulted. 




Hare-lip. 



Cleft Palate. — Etiology. — What has been said in regard to the 
etiology of hare-lip applies largely to cleft palate. Cleft palate may 
be single or double. The fissure may involve only the soft palate and 
uvula, and this is- the most common form, it may involve more or less 
of the hard palate, or, in rare cases, the palate alone. It may or may 
not be associated with hare-lip. 

Pathological Anatomy. — Deformity results from the failure of perfect 
fusion between the hard palate and the intermaxillary bone, as well as 
imperfect union of the vomer and the velum. 

Symptoms. — The child has marked difficulty in both nursing and 
swallowing, as the milk may regurgitate through the nose. The infant, 
breathing, as it does, through the mouth, is exposed to the danger of 
infection of the nose, throat, and lungs. Speech is always impaired; 
the voice has a nasal tone, and many of the consonants are imperfectly 
articulated. Owing to the mechanical difficulty in feeding these 



CONGENITAL MALFORMATIONS OF THE TONGUE 85 

children, they arc often small, ill-nourished, and delicate, and their 

nutrition and general care become a matter of the first importance. 
It is absolutely necessary that the nasal pharynx be kept clean, yet 
care must be taken never to exert more than the minimum amount of 
force, since these mucous membranes are easily injured mechanically. 
They are also especially liable to be affected with thrush, which may be 
a serious complication, particularly if the child is weak and frail. A 
weak alkaline and mildly antiseptic wash may be employed to keep the 
nasal pharynx clean, especially before and after feeding. 

Prognosis. — The prognosis depends, as does that of hare-lip, on the 
physical condition of the child. The mortality from the operation is 
3 per cent. 

Treatment. — Many surgeons prefer to operate as soon after the 
thirteenth or fourteenth month as the child's physical condition will 
permit, and the operation should always be performed before the 
beginning of the third year. If a large fissure remains after the first 
attempt at closure, a second operation is indicated; but a small fissure 
can often be closed by local applications. It is claimed that, if possible, 
the repair of a cleft palate should be accomplished before the period 
when the child ordinarily begins to talk, and that, as a result of this, 
systematic exercises directed toward improvement of the speech are 
a valuable aid which should, moreover, be begun before bad habits 
of speech are formed. On the same principle, it is important that 
everything possible should be done to improve the general health 
and nutrition of the child, both before and after operation. Breast 
milk is, of course, the best food for these infants, and it may be 
necessary to feed them with a spoon, medicine dropper, or a Breck 
feeder. An admirable arrangement consists in attaching to the ordinary 
nursing nipple a flap which more or less perfectly fits the roof of the 
mouth and assists, partially at least, in closing the fissure. 

During the period of residence in the hospital, both before and 
subsequent to operation, gavage is of advantage, since by this method 
a larger amount of food can often be introduced into the stomach. 
After leaving the hospital it is applicable only to those cases where a 
trained nurse is in attendance. 

CONGENITAL MALFORMATIONS OF THE TONGUE. 

Tongue-tie. — This condition consists in a shortening of the frenum 
of the tongue to such an extent as to render the protrusion of the 
tongue beyond the lips difficult, and it is also bound down to the 
floor of the mouth by the unnaturally tight and short frenum. Articu- 
lation may be more or less interfered with, and sucking may be 
imperfect. It is a common experience with all physicians to be con- 
sulted in regard to children two or three years of age who are supposed 
by their parents to be tongue-tied because they do not talk. In the 
large majority of such cases, the failure to talk is not in any way 
connected with the tongue, but is significant of some mental condition 



86 CONGENITAL MALFORMATIONS 

or deaf mutism. The treatment of tongue-tie is simply the elevation 
of the tongue by passing the slit of a groove director over the frenum, 
and nicking the frenum slightly with a pair of blunt scissors. If the 
cut is made close to the gum the artery is easily avoided. 

Macroglossia. — Macroglossia, giant tongue, or hypertrophy of the 
tongue, is usually a symptom of some general pathological condition 
such as cretinism, idiocy, mongolism, and acromegaly. In some 
patients, however, it may be due to a more or less advanced 
hemangioma or lymphangioma of the tongue, according to whether the 
cavities of the tongue show enlarged bloodvessel involvement or 
enlarged lymphatics. This condition is usually progressive, the tongue 
steadily growing larger until finally, owing to its great size, it protrudes 
more or less from the mouth, and plainly shows the marks made by the 
pressure of the teeth. It may become so large that swallowing and 
even respiration are interfered with. A few cases are on record where 
increase in size has been the result of hypertrophy of the muscular fibers. 

Thyroid extract is, of course, the proper treatment in cases due to 
cretinism. In other conditions the size has been reduced by the 
thermocautery or excision. If the entire tongue is involved, portions 
of the growth may be removed by successive operations. On account 
of the danger of hemorrhage, the lingual arteries should be ligated 
before operation. 

Ranula. — A ranula is situated beneath the tongue, and is caused 
by the duct of the sublingual glands or of the mucous glands becoming 
occluded. The secretions of these glands are consequently retained, 
and the cyst or ranula develops. As the cyst increases in size it causes 
a protrusion or swelling of the mucous' membrane beneath the tongue, 
which is gradually lifted and pushed upward. The swelling presents a 
bluish appearance, is translucent, painless, and gives a feeling of 
fluctuation. It contains a thick, viscid, colorless fluid. The cure of the 
ranula is best accomplished by its total extirpation, although it may 
often be brought about by cutting out as large a portion as possible of 
the anterior wall, and touching up the interior of the sac with tincture 
of iodine or nitrate of silver, five grains to the ounce. Simple incision 
and evacuation of the sac is not to be recommended ; such an incision, 
as a rule, rapidly heals and the sac refills. 

CONGENITAL DISEASES OF THE NECK. 

Fistulse of the Neck. — Etiology. — The incomplete fusion of certain 
primitive or embryonic structures results in these malformations. 
Lateral fissures are the result of imperfect development in the branchial 
clefts, and a median fissure is associated with imperfect development 
of the median lobe of the thyroid. Heredity, alcoholism, and amniotic 
bands are operative here as causative agents, just as they are in hare-lip 
and cleft palate. 

Symptoms. — At the middle or along the sides of the neck small 
fistulse are occasionally found which exude, normally or under pressure, 



CONGENITAL DISEASES OF THE NECK 87 

a whitish liquid. The lateral fissure may cud in a cul-de-sac, or open 
internally in the neighborhood of the tonsil. The external opening 
coincides with the anterior margin of the sternocleidomastoid muscle. 
The fistula? in the middle line of the neck, if not blind, open under the 
tongue. 

Treatment. — The treatment consists in the total extirpation of the 
fistula? and the cyst, as experience has shown that any operation or 
treatment other than this is useless. 

Congenital Cystic Lymphangioma of the Neck.— Pathological Anat- 
omy. — This malformation is composed of dilated lymphatic vessels, 
which become cysts, and adhere closely to the neighboring skin. 
muscles, and bloodvessels, the tumor usually increasing rapidly in size. 

Symptoms. — The tumor develops in the side of the neck, and is 
composed of many cysts. It tends to grow downward below the 
clavicle, and may even penetrate into the dee]) tissues of the larynx 
and esophagus. As the tumor becomes larger, difficulty in swallowing 
and oppression in breathing develop, which become more marked as 
the pressure from the enlarging mass increases. 

Prognosis. — The prognosis is unfavorable as, unless the diagnosis is 
made early and the tumor completely removed, recurrence is likely. 

Treatment. — Its complete extirpation is always rendered difficult 
on account of its close adhesion to all neighboring structures; but 
only radical extirpation will bring about a cure, and it is therefore most 
important that the diagnosis be made early, since, owing to the rapid 
growth of these tumors, the difficulties and dangers attending radical 
operations increase with any delay. If the operation be only partial 
or incomplete, it will be followed by relapse and the continued new 
growth of the mass. As there is no communication between the cysts, 
their formation being much like that of a bunch of grapes, puncture 
accomplishes little. 

Congenital Torticollis. — Etiology.— Heredity is undoubtedly a factor, 
as are also intra-uterine inflammations and adhesions. A traumatic 
injury to the sternocleidomastoid muscle during delivery may be 
followed by slow interstitial inflammation in the muscle tissue, the 
contraction resulting therefrom producing the typical deformity. 

Symptoms. — The position of the head is caused by the contraction 
of the affected sternocleidomastoid muscle. The head is rotated 
toward the unaffected side, and deflected toward the diseased side, 
and is held fixed in this position. The sternal portion of the muscle 
produces the rotation of the head, and the clavicular the deflection. 

Diagnosis. — The muscle can be felt as a firm hard band. It should 
be remembered that diseases of the upper cervical vertebrae and 
occipital periostitis are capable of producing torticollis, and that 
the diagnosis of tuberculosis in this upper spinal region can be often 
corroborated by £-ray plates. 

Treatment. — The treatment of congenital torticollis is operative; 
either open section or partial extirpation of the diseased muscle is the 
operation of choice. Open section of the muscles is to be preferred 



88 CONGENITAL MALFORMATIONS 

to subcutaneous section as being more thorough and less apt to injure 
the large bloodvessels. The lower portion of the muscle, dividing 
as it does into two parts, is the place of election for operation. The 
spinal accessory nerve is in this region, and care must be taken to 
avoid injuring it. After operation the head is fixed by pads and 
bandages in a position of overextension. If any scoliosis has developed 
as a result of the torticollis, it must receive appropriate treatment. It 
seems almost unnecessary to urge the necessity of early operation 
in congenital torticollis. During the first few weeks of life a pad may 
be w T orn and daily massage employed, and if, at the age of three months, 
there is not distinct improvement an operation should be performed. 
Firm and fixed scoliosis has not occurred at this period, and the sub- 
sequent result is better and treatment is simpler if the operation is 
performed at this early age. Torticollis is often only a symptom, and 
in these cases it is necessary to treat the underlying cause as well as the 
torticollis. 

CONGENITAL MALFORMATIONS OF THE ESOPHAGUS. 

Congenital malformations of the esophagus include absence of the 
esophagus, in whole or in part, stenosis of varying degree, dilatation, a 
bending or twisting of the canal, and fistula? communicating with 
the trachea. 

Symptoms. — Vomiting is, of course, the cardinal symptom. If the 
stenosis is of such degree as to permit the slow trickling of fluids 
through the passage, a small amount of liquid nourishment may be 
ingested and retained; whereas, if a large amount is given, a portion 
of it is always vomited. If solid or semisolid food blocks the small 
aperture in the esophagus, the giving of such food may be followed by 
vomiting of almost all nourishment so long as the more solid material 
continues to occlude the small esophageal opening. Congenital 
obstruction is undoubtedly much more common than was formerly 
supposed, and cases of persistent vomiting in young children should 
be studied with this possible diagnosis in mind. 

Treatment. — The treatment is most unsatisfactory. Stenosis of 
moderate degree has been successfully treated by dilatation; for the 
other conditions gastrostomy is necessary, after which an attempt 
can be made to feed the child through the artificial gastric fistula. 
If the infant's strength will permit, an effort may be subsequently 
made to overcome the congenital defect by surgical measures. As the 
operation, except in cases of moderate stenosis, usually has to be per- 
formed when the infant is only a few days old, the risk attending it is 
of course very great. The condition of cardiospasm may be congenital; 
it is not a malformation, and can usually be treated successfully; still 
it may in early life produce symptoms identical with those of organic 
stenosis, hence its existence should be borne in mind. 

Meckel's Diverticulum. — Meckel's diverticulum is a persistence of 
the ductus omphalomesentericus. 



CONGENITAL MALFORMATIONS OF Till-: ESOPHAGUS 89 

Etiology. This duct, which normally exists in the fetus and connects 
the intestine and the vitelline membrane, closes at about the end of the 
second month. The canal or duet arises from the lower portion of the 
small intestine, about twelve inches above the ileocecal valve. It may 
be a cul-de-sac a few inches long, or it may remain open as far as the 
umbilicus, and permit the passage of fecal matter. The mucous 
membrane of the duct may prolapse through the umbilicus, producing 
a small tumor. Instead of persisting as an open or closed duct, this 
congenital condition may exist as a cord extending from the lower 
ileum to the umbilicus, and a portion of the bowel may be caught and 
constricted by this cord, and intestinal obstruction and strangulation 
produced. It must be remembered that this condition is possible in 
child or adult life as well as in infancy. In those children in whom 
the duct remains open a discharge of mucus or feces will occur at 
the umbilicus. If the umbilical end of the duct is obliterated a cyst 
is formed at the umbilicus. This is reddish, globular, and usually 
contains a whitish secretion. Occasionally, if the lumen is sufficient, 
the intestine may be drawn into this cyst, and intestinal obstruction 
thus develop. A twisting of the pedicle of the duct may lead to intes- 
tinal perforation and resulting peritonitis; an intestinal stenosis from 
the prolapse of the ductus into the lumen of the intestines has been 
observed, and intussusception may be produced by inversion of the 
duct. Perforation of the diverticulum with resulting peritonitis 
may be induced by ascarides in its lumen, or fecal impaction, or any 
cause which may produce localized inflammation and necrosis. Adeno- 
mata may develop from the tissues of the duct, and present themselves 
as a tumor of the umbilicus. 

Symptoms. — Symptoms of intestinal obstruction or strangulation 
are possible as a result of Meckel's diverticulum. They may be caused 
by a prolapse of the diverticulum into the bowel, or the band-like 
cord which may exist, instead of the more or less patulous duct, 
may cause a sufficiently tight constriction of a loop of intestine to 
produce strangulation. 

Diagnosis. — The presence of a feeal discharge at the umbilicus is 
strongly suggestive of Meckel's diverticulum. In a fistula of the 
urachus, the direction of the fistula is toward the bladder, and the 
reaction of the discharge is acid. A fistula of the urachus is also indi- 
cated if any of the normal ingredients of urine can be demonstrated 
in the discharge. An alkaline reaction suggests a connection with 
the lower bowel. If any connection with the bladder exists, methy- 
lene blue injected into the fistula will later show itself in the urine. 
In fistula of the urachus prolapse of the mucous membrane may 
also cause a tumor at the umbilicus, but this is comparatively 
rare. 

Prognosis. — It depends upon the patulous condition of the duct; 
the persistence of the duct as a cord or band ; the presence of a tumor 
at the umbilicus and the contents of this tumor; and the healthy 
or diseased condition of the walls of the duct. 



00 CONGENITAL MALFORMATIONS 

Treatment. —The removal of the diverticulum is the proper treat- 
ment. An incision made along the median line of the rectus permits 
its complete removal and the invagination of the stump. The com- 
plication of tumor at the umbilicus must, of course, be treated surgically. 

HERNIA OF THE UMBILICAL CORD. 

In the development of the fetus the intestines lie outside the 
abdominal walls, the closure of the abdomen being brought about by 
the fusion of two sides of the abdominal walls. In this developmental 
process the bowel appears in the umbilical cord, and is covered by 
peritoneum; Wharton's jelly, and amnion. 

Symptoms. — The tumor is usually of small size, although occasionally 
it is quite large. It contains, perhaps, a loop of intestine, Meckel's 
diverticulum, or it may, if of large size, contain one or more abdominal 
organs, possibly the liver, spleen, pancreas, or kidney. The mass is 
situated at the umbilicus, and the umbilical cord is a part of, and 
extends beyond, the tumor. 

Prognosis. — The prognosis is fatal unless the condition is of such a 
nature that it can be immediately relieved by operation. It is danger- 
ous to ligate these tumors without first opening them and assuring 
one's self that the mass does not contain any coil of intestine. If the 
tumor is small, the method advised by Olshausen of making an incision 
in the healthy skin surrounding the tumor, detaching the amnion 
from the inner membrane in Wharton's jelly, reducing the hernia, 
and closing the skin over it has been practised with success. In this 
operation the peritoneum is not opened. Large tumors, if containing 
only intestine, may be operated upon, and at times successfully, by 
opening the hernial sac and returning the contents within the abdomen. 
If the tumor contains any large part of one or more of the abdominal 
organs, the operation is both a dangerous and difficult one, and infec- 
tion of the peritoneum frequently results. Cases have been reported 
where the cautery has been used successfully to remove the middle 
lobe of the liver which has been found in the hernial sac. 



UMBILICAL HERNIA. 

Normal development causes the complete closure of the abdominal 
walls with the exception of that small portion at the navel which 
must remain open in order that the umbilical vessels be patulous. As 
the cord desiccates and is detached, this small opening has a normal 
tendency gradually to close, and, after the cord has fallen, the only 
use of the abdominal binder is to hold a small compress over this still 
unclosed umbilicus. As the child grows very rapidly at this period, 
the tissues fill up this unclosed portion, and it soon becomes obliterated. 
If the infant is premature, frail, or badly nourished, closure may not 
take place; this is more common in girl infants. Severe crying, 
coughing, or marked abdominal distention also has a tendency to 



Umbilical heMia 



91 



prevent closure, as docs traction of the umbilical cord. The coverings 
of the bowel in the hernia arc skin, transverse fascia, and peritoneum. 

Symptoms. — This form of hernia rarely produces any symptoms. 
It may, however, gradually increase in size, especially if constipation, 
cough, and much abdominal distention are present, and is often much 
increased later in life by pregnancy. 

Treatment.— Prophylaxis embraces the wearing of a snug, but not 
tight, abdominal binder, with a small retaining pad over the navel. 
This should be worn at least during the first two months, or longer if 




Fig. 13. — Adhesive plaster applied for umbilical hernia. 



necessary. As soon as the hernia is discovered, it should be returned 
within the abdominal cavity and retained by doubling in over the 
umbilicus two longitudinal folds of tissue, one from either side of the 
abdominal wall and on opposite sides of the umbilicus, and retaining 
these folds in place with two broad strips of zinc oxide adhesive plaster. 
If properly applied, these strips will remain in position for some days, 
and will produce very little irritation of the skin. They should extend 
from one side of the outer abdominal wall across to the other, that is, 
about half way around the child's body (Fig. 13), and this method 



02 CONGENITA L MA LFORMA TIONS 

of treatment should be continued for two or three months, or longer if 
the hernia persists. It is much more liable to result in a cure than the 
application of the ordinary umbilical truss with a conical projection 
which fits into the opening and really tends to prevent its closure. 
A flat object, such as a coin, may be covered with zinc oxide plaster, 
and retained over the umbilical opening with adhesive strips. The 
skin must always be kept absolutely sweet and clean. It is extremely 
difficult — in fact, almost impossible — to retain in proper position 
any form of apparatus on a child who has reached the walking age. 
In older children many of these umbilical hernise, if small, gradually 
tend to close as the child grows and develops, and it has rarely, in 
my experience, been necessary to resort to surgical treatment. How- 
ever, if the hernia is large and especially if, in a girl, it tends to 
enlarge, a surgical operation, is undoubtedly the proper treatment. 

CONGENITAL DILATATION OF THE COLON. 

Congenital dilatation of the colon, or Hirschsprung's disease, is a 
rare congenital affection. 

Pathological Anatomy. — The colon is longer than normal, is con- 
voluted, greatly dilated, and the muscular walls of the dilated portion 
are usually much hypertrophied. In some cases the transverse portion 
of the colon is affected, and in others the descending portion of the 
colon and the sigmoid flexure. The dilatation produces constipation, 
and the materials retained in the bowel undergo fermentation and 
decomposition which tend still further to increase the dila- 
tation. 

Symptoms. — The most marked symptom is constipation, which may 
be present at birth, or, if not, develops soon after, and is shortly 
followed by abdominal distention. The infant, and especially the older 
child, will often go for a number of days without a stool, this constipa- 
tion being followed by a conservative diarrhea which partially clears 
out the bowel, the stool consisting of hard, lumpy masses of fecal 
matter and much mucus. Enemata are only fairly successful in 
bringing away the retained fecal mass, and large doses of laxatives 
usually become necessary. The infant, and later the child, is weak and 
emaciated, and the contour of the enormously distended abdomen often 
changes in a curious way while it is being examined, as a result of the 
gas moving from one portion of the bowel to another, and the coils of 
enlarged intestine can often be outlined through the thin abdominal 
walls. After the administration of purgatives, large masses of feces 
are passed with much flatus, and the abdominal distention is, to a 
slight extent, temporarily lessened. Intestinal toxemia of more or less 
marked degree is often present, and in most cases that come to opera- 
tion or autopsy the mucosa of the bowel shows superficial ulceration. 
A stricture below the dilatation has not been observed. The child 
becomes anemic and cachectic, and in infants severe nervous symptoms 
are not uncommon. The exact size, shape, and location of the colon 



ATRESIA OF THE BOWEL 93 

can be absolutely mapped out by giving the child a bismuth meal, or 
injecting the colon with bismuth, and then taking .r-ray plates. 

Prognosis. — These infants are all under weight, and, owing to their 
poor physical condition, many of them die of inanition or secondary 
diseases. If the dilatation is slight, they may reach adult life, but 
the majority of the severe cases die in infancy. A number of cases 
are on record in which the dilated colon has been successfully removed 
by operation. 

Treatment. —Medical treatment can, at least, alleviate the symptoms, 
and make the child more comfortable. The most important object 
to be accomplished is to build up as well as possible the child's general 
health. Fresh air, an easily digested and nourishing diet, selecting 
those foods that are best adapted to the child's digestion, will help 
to maintain bodily weight and vitality. Daily irrigation of the colon 
with two quarts of warm salt solution is a valuable aid in overcoming 
the constipation, and tends to cleanse, at least, the lower portion of tin' 
large bowel. A daily laxative, such as podophyllin or cascara, is of 
service, although it is advisable to change the laxative from time t<> 
time, as the child will otherwise require increasing doses. Abdominal 
massage, especially over the colon, will assist in promoting peri- 
stalsis. Give the child plenty of water to drink, and establish regular 
hours for him to go to the toilet. The habit of placing small children 
at a certain hour each day on the chamber is, in my experience, the 
most essential part of the treatment of constipation, no matter what 
its cause. If the above outlined medical treatment were instituted 
as soon as the first evidences of constipation were observed, it would 
probably be effective in a small proportion of cases. This is, however, 
rarely possible except among the most intelligent classes, and the 
failure of the child to gain in weight and strength, or its progressive 
loss in strength, often makes a surgical operation the only pro- 
cedure. 

Formerly an artificial anus was the usual operation, the opening 
being made in the bowel above the dilated portion. This puts largely 
at rest any portion of the colon which is abnormally dilated, and the 
physiological rest enables it to regain in part its normal vigor and tone. 
A second operation is then performed to close the artificial anus and 
reestablish the normal passage of the feces per rectum. Recently the 
tendency has been to remove the dilated portion of the colon, and 
while it is a very serious and radical operation it has, nevertheless, 
been performed successfully in a few cases. Some surgeons divide 
the operation into two stages, in order to lessen shock. It is to be 
sincerely hoped that with advance in modern surgery this operation 
will soon be established on a firm basis. 

ATRESIA OF THE BOWEL. 

The principal etiological factors are peritonitis, volvulus, and syph- 
ilis. Fetal peritonitis manifests itself by an inflammatory exudation 



94 CONGENITAL MALFORMATIONS 

resulting in adhesions formed between coils of intestine. Volvulus is 
the probable cause when atresia is found in several different portions 
of the bowel. 

Location and Variety of Malformations. — The most common location 
is at the anus. The anal opening may be the only part that is defective, 
everything else being normal. The normal anal opening may be 
present, and nothing but a delicate septum interfere with the normal 
passage of feces. In other cases the location of the anal orifice may 
be simply represented by a dimple, the rectum ending in a cul-de-sac. 
This cul-de-sac may be situated very close to the normal anal opening, 
or it may be so far removed from this position that a long and, perhaps, 
difficult dissection may be necessary to establish an anal opening. 
The intervening space between the two points of atresia of the bowel 
may be replaced in either the entire or a portion of the distance by a 
fibrous cord. 

In another form of malformation, the anal opening and adjacent 
portion of the rectum are present, but end in a cul-de-sac. The distal 
portion of the bowel may immediately join this cul-de-sac, being, per- 
haps, separated by only a delicate septum, or a considerable space 
may intervene between the two extremities of the bowel. The rectum 
may open internally into the bladder, or a fistulous opening may con- 
nect the rectum and bladder; in other cases, the rectum is connected 
with the urethra or with the vaginal vestibulum. 

Symptoms. — The symptoms vary according to the location of the 
obstruction. If the fecal contents do not escape through some fistulous 
tract, the condition invariably produces constipation, followed by 
dilatation of the portion of the bowel immediately above the obstruc- 
tion, and subsequent vomiting. If the obstruction is in the small 
intestine, especially if in the upper portion, vomiting is an early 
symptom, and is persistent. The portion of the bowel below the 
obstruction is emptied of meconium, and the subsequent stools contain 
nothing but mucus. These cases are conspicuous by the rapid loss of 
flesh, increasing asthenia, and early death. With the exception of the 
lower end of the rectum, the upper portion of the small intestine is the 
most common seat of intestinal atresia. If the obstruction is only 
partial, the symptoms are less pronounced, and the child's life, unless 
a surgical operation be performed, depends upon the amount of food 
that trickles through the constricted portion. The constipation in 
these cases is, of course, in proportion to the degree of stenosis, which 
limits the amount of food that passes on into the lower bowel. The 
portion of the bowel above the atresia is always distended and dilated, 
while that below is small in calibre, and generally poorly developed. 
If the urine at any time contains fecal matter, a communication 
between the rectum and the bladder will be naturally suspected. 

Diagnosis. — An absence of the normal anal opening should be dis- 
covered during the first bathing and cleansing of the infant; otherwise, 
there is nothing at birth that would cause one to suspect the malforma- 
tion. Vomiting soon after birth associated with constipation and 



MALPOSITION OF THE BOWEL 95 

abdominal distention suggests an obstruction high up in the small 
bowel, while constipation followed by abdominal distention and 
vomiting suggests an obstruction low down in the bowel. In atresia, 
where the anal opening is present, and a small portion of the adjacent 
lower bowel also, a finger inserted in the rectum discloses the fact that 
the bowel ends in a cul-de-sac. If the examining finger discloses a 
mass which presses down against it on crying, the amount of tissue 
lying between the upper and lower portion of the bowel may probably 
be more or less accurately estimated. 

The diagnosis may be confused by the fact that the obstruction is 
present at more than one point, and a bismuth meal and z-ray plates 
may be of assistance in diagnosing this condition. Possibly they may 
assist in locating the site of the lesion, particularly in those cases where 
a fistula allows some of the fecal matter to pass beyond the point of 
obstruction, or may aid in locating the several points of, possibly, 
partial obstruction, atresia of the bowel not being complete, but the 
condition being one of stenosis. Injections of bismuth per anum may 
also be of advantage in those cases where the lower portion of the 
large bowel, extending upward from a normal anal orifice, ends in a 
cul-de-sac. 

Prognosis. — The infant at birth has, of course, little power to endure 
a severe surgical operation, and, except in those cases where the 
obstruction is situated near the anal region, the condition is usually 
fatal. If, however, the bowel contents empty externally by means of 
a fistula, the prognosis as to life is good. 

Treatment. — With the exception, however, of such cases, all patients 
will require a surgical operation to effect a cure. 

MALPOSITION OF THE BOWEL. 

Malpositions of the bowel are now more often recognized and under- 
stood, owing to the taking of .T-ray plates after bismuth meals, but one 
must not be too positive in regard to the permanent position of any 
particular portion of intestine after one £-ray examination. I have, 
in a number of cases, seen se-ray plates which showed portions of the 
bowel evidently much out of position as a result of an unnaturally 
long and loose mesentery, where, in a plate taken later, the bowel 
had practically returned to its normal position. A portion of intestine 
situated temporarily out of its normal position, may or may not be the 
cause of symptoms, and even if one is reasonably sure that certain 
symptoms are the result of the malposition, it is wiser in the majority 
of cases to avoid, if possible, surgical interference, in the hope that the 
bowel may return to a more normal position and the symptoms dis- 
appear. If the displaced portion of the bowel is fixed in its new 
position and produces no alarming symptoms, it should be carefully 
watched ; if the symptoms persist and are of a sufficiently severe type 
to warrant it, surgical interference is indicated. 

The bowel may be in malposition in a congenital umbilical hernia 



90 



( "ON GEN I TA L MA WORM A TIONS 



which may contain more or less intestine; also in a diaphragmatic 
hernia which may contain coils pushed through the diaphragm up 
into the thorax. 

EXSTROPHY OF THE BLADDER. 

In these patients the bladder is situated outside of the abdominal 
wall, and the malformation is the result of arrested development 
which creates a fissure in the abdominal wall. It is by some believed 
to be the result of the bursting of the allantois, caused by an unusual 
amount of secretion before the lower aperture for its escape had been 
formed. 




Fig. 14. — Exstrophy of the bladder and epispadias in a child five months old. 

Pathological Anatomy. — The anterior part of the abdominal wall is 
absent, and there are often other congenital malformations, among 
which is an absence of union at the symphysis pubis. The fissure may 
extend to the urethra" with epispadias, fissured scrotum, and unde- 
cended testes in the male, and open urethra and fissure of the labia and 
clitoris in the female. 

Symptoms. — The mucous membrane protrudes through a fissure in 
the abdominal wall; it is of normal color, is folded into ridges, and 
is continuous with the skin of the abdomen. Any increase of intra- 
abdominal pressure causes a still further protrusion of the mass. The 
openings of the ureters are situated in the low T er portion of the tumor. 
The urine dribbles continuously, and causes a most annoying irritation 
of the skin. This, associated with the continual odor of urine, makes 
all patients who have arrived at an age when they can appreciate 
their condition only too willing to submit to a surgical operation. 



UNDESCENDED TESTES— CRYPTORCHIDISM 97 

Prognosis. — Many of these children, if unoperated upon, die from 
infection of the bladder and kidneys. A number have been succor- 
fully operated upon both in child and young adult life. 

Treatment. — The treatment is, of course, purely surgical; either the 
covering up of the defect in the anterior wall with a skin flap and the 
formation of a new urethra, or the implantation of the ureters into 
the intestinal tract, is the operation now most popular. Very favor- 
able results have followed the transplantation of the ureters into the 
rectum; the patient develops a control of the urine which may last 
for hours during the day or night. The results are often so satisfactory 
that it is wise to give all cases the benefit of an operation. 




Fig. 15. — Exstrophy of the bladder in a child seven months old. 



UNDESCENDED TESTES; CRYPTORCHIDISM. 

The testicles develop in the abdomen, and usually descend into the 
scrotum in the last few weeks of intra-uterine life. It is not uncommon, 
however, to find one or even both of them in the abdominal cavity 
in an infant otherwise normal and healthy and born at full term. 
Ordinarily we find that one testicle has descended into the scrotum 
while the other is still retained in the inguinal canal. As a rule, it 
descends in the first few weeks of life, its retention having produced 
no symptoms, and after its descent the inguinal canal usually closes 
normally. It may be retained, however, either within the abdominal 
cavity, or at the entrance, or in some portion of the inguinal canal for 
months or years; occasionally, possibly owing to its increased size 
and weight, it descends into the scrotum. This may occur at any time 
in the child's life up to the age of ten years. The longer it remains 
out of its normal position, the less likelihood is there of its descending 
into the scrotum. In the inguinal canal it is exposed to traumatism, 
and as puberty approaches it is apt to cause a nauseating pain; often, 
if out of its normal position, it does not develop properly, and an 
7 



98 CONGENITAL MALFORMATIONS 

undescended testicle is more liable to become diseased than one in 
normal position. If it remains in the canal, it predisposes to 
hernia. 

Diagnosis. — The absence of the testicle in the scrotum can hardly 
escape the notice of the mother or nurse. By passing the little finger 
up the inguinal canal, the testicle can usually be felt either in the 
canal or at the internal opening of the abdomen. 

Treatment. — In a young infant it is, in some cases, possible by gentle 
manipulation to push the testicle downward, perhaps into the scrotum; 
this may assist in restoring the organ to its normal position, and, if 
performed gently, does no harm and may, possibly, do good. If at 
the age of ten years the testicle has not descended, the recognized 
operation of the day is to transplant the organ into the scrotum, which 
is usually possible of accomplishment. If, however, in any particular 
case, this operation cannot be performed, it is wiser to return the 
organ into the abdominal cavity. If the testicle becomes diseased, 
and it is a well-known fact that in its unnatural position it is more 
likely to undergo certain degenerative changes, it should be immedi- 
ately removed; but its removal should never be advised unless it has 
undergone some such change. 

HYDROCELE. 

Hydrocele, of which there are several forms, is a collection of fluid 
in the tunica vaginalis, and is a very common condition in the infant. 
It is caused by a failure of fusion of the pars vaginalis of the peritoneum, 
and in about 50 per cent, of newborn infants the processus vaginalis 
is still open. 

Congenital Hydrocele. — In this variety the fluid occupies a position 
in the umbilical canal between the peritoneal cavity and the tunica 
vaginalis. The fluid will flow back into the abdominal cavity if the 
child is placed in the horizontal position and a moderate amount of 
taxis employed. 

Hydrocele of the Tunica Vaginalis. — This is the most common form 
and is irreducible. The inguinal canal becomes closed off from the 
abdominal cavity, but still communicates with the tunica vaginalis. 
The tumor is oval, firm to the touch, translucent, and usually one- 
sided. Fluctuation can generally be obtained. Ordinarily the testicle 
cannot be found by manipulation. 

Encysted Hydrocele of the Cord. — This consists of a small amount 
of fluid, usually about one or two drams, surrounding a portion of the 
cord. There is no communication with the tunica vaginalis testis, 
and the tumor is irreducible. The same condition when found in 
girls is called encysted hydrocele of the canal of Nuck, and requires 
the same treatment. 

Diagnosis. — About the only condition with which hydrocele is apt 
to be confounded is an irreducible hernia. A hard, tense, irreducible 
tumor, which has been present for some time, which has not been 



OBLITERATION OF THE BILE DUCTS 99 

and cannot be reduced, which produces no symptoms, and is not 
painful on pressure, is a hydrocele. 

Treatment. — The simplest, and often the only treatment, is to 
puncture the cyst and draw off the fluid, which is best accomplished 
with a small aspirating needle. If after three such withdrawals cure 
has not resulted, surgical measures should be resorted to. The best 
treatment for the reducible form of hydrocele is to return the fluid by 
means of gentle taxis into the abdominal cavity, and then apply a 
truss with the hope that pressure may not only prevent the return of 
the fluid, but also gradually produce obliteration of the canal. Injec- 
tions of iodine into the hydrocele sac are not to be recommended; 
the subsequent inflammation is often very severe, and in those patients 
in whom the canal is still open, the procedure is attended by a certain 
amount of danger. Phimosis which causes tenesmus and consequent 
increase of intra-abdominal pressure should be operated upon. The 
surgical operation, of choice, is extirpation of the hydrocele sac. 




Fig. 16. — Hydrocele in an infant aged six months. 

OBLITERATION OF THE BILE DUCTS. 

The common hepatic or cystic duct may be obliterated as the result 
of imperfect development. A narrowing of the lumen of one or more 
of these ducts results in inflammation of their lining membrane which 
finally stops entirely the flow of bile. Either the common duct alone 
may be affected, or the hepatic or cystic duct may be the one involved. 
Intra-uterine peritonitis is probably secondary to the atresia of the 
bile ducts. In about 10 per cent, of these cases there is a history of 
syphilis. The gall-bladder is small, often only rudimentary, although 
in atresia of the common duct it may be greatly distended. The 
liver is usually much enlarged and shows the changes due to chronic 
interstitial hepatitis. The spleen is enlarged, and the bile duct may be 
reduced to a fibrous cord. 



100 CONGENITAL MALFORMATIONS 

Symptoms. — All the tissues and organs of the body are deeply 
jaundiced, and hemorrhages beneath the skin, with vomiting of blood 
and blood in the stools, occur in some cases. Jaundice is the most 
marked symptom; it develops usually within a few days after birth, 
and progressively becomes more pronounced. The urine is very 
high-colored owing to the presence of bile pigment. Shortly after 
birth small stools composed of meconium may be passed; later the 
stools are clay-colored or white, and examination shows them to 
contain no bile except in those cases where the blocking is limited 
to the cystic duct. The child may be well-nourished at birth, but soon 
loses flesh, and death from inanition occurs in the course of a few weeks 
to four months. Marked abdominal distention with toxemia, as 
evidenced by convulsions, is a not unusual symptom, and convulsions 
are a not uncommon cause of death in those infants who live but a 
few weeks. 

Treatment. — This exerts no influence upon the symptoms or the 
course of the disease. 

SPINA BIFIDA. 

Spina bifida consists of a fissure in the spinal canal with a hernia 
of some portion of its contents, the portion that protrudes forming 
a tumor posteriorly. Fluid is always present in the tumor. It is one 
of the most common congenital malformations. The walls of the 
tumor, according to the intra-uterine period in which the defective 
development occurs, may contain a portion of one or of all the follow- 
ing structures: Spinal cord, nerves, meninges, and vertebral arches. 
The tumor, in rare instances, instead of appearing posteriorly through 
a fissure in the bony spine, may project anteriorly into the thorax 
or abdomen. These tumors resemble hernia of the brain in pathology 
and in mode of development. There are several varieties of spina 
bifida, although all present two features in common: a defect in the 
bony spinal column and a lesion in the spinal canal. All result from an 
error in development. The spinal canal closes at different places at 
varying stages in the development of the fetus, the lower lumbar and 
upper cervical being the last portions to unite, and these two locations 
are the places in which the deformity usually occurs. In all forms 
a>ray plates will show the bony defect. 

Spinal Meningocele. — In this variety of spina bifida a tumor is 
found in the cervical or sacral region. It is translucent, globular, 
and pedunculated. As a rule, there is no disturbance of sensation or 
motion. The tumor contains only the spinal meninges and cerebro- 
spinal fluid. The fluid is in the subarachnoid space. The opening into 
the spinal canal is small, and the skin over the tumor is firm and 
healthy. This form may become quite large, but spontaneous rupture 
is not very likely to occur owing to the healthy condition of the 
overlying skin. Patients with this form of tumor may live for years— 
in fact, well into adult life. It is the least dangerous form to operate 
upon, and the easiest to cure by an operation. 



SPINA BIFIDA 101 

Myelomeningocele. This is the most common form of spina bifida, 
especially in the lumbosacral region. The fluid is in the anterior 

arachnoid cavity. The tumor is not large, but has a large base, is soft, 
flat, elastic, and not pedunculated. Often it is covered only in part 
by skin; the central portion of the tumor being covered by a thin 
tissue, commonly showing ulceration. A depression in this central 
part marks the position of the attachment of the cord. The tumor is 
composed of the prolapsed spinal cord. Paralysis of the bladder, 
rectum and lower limbs, and deformities of the foot may accompany 
this form. 

Myelocystocele. — This is the rarest form. It is found in the dorsal, 
lumbar, or sacral regions, and may be combined with abdominal 
fissures and club-foot. The tumor is round with a wide base, is elastic, 
transparent, and fluctuates. It may also be associated with hydro- 
cephalus, and in this form there is a dilatation of the central canal 
of the cord. The wall around the sac is composed of medullary sub- 
stance. If hydrocephalus is present the prognosis is less favorable, 
and pressure upon the anterior fontanelle causes an increase in the 
size of the tumor. There is usually no paralysis. The skin covering the 
tumor is very thin. 

Spina Bifida Occulta.— This consists of a slight fissure or defect 
at the inferior end of the spinal canal; it is covered by normal skin. 
Here, as in the other forms, the .r-rays will reveal the bony defect. A 
small tumor may show itself or none may exist, the spinal defect being 
indicated only by a slight depression or dimple in the overlying skin. 
A swelling in the sacral region associated with any neighboring trophic 
changes, or paralysis of the rectum, bladder, or lower extremities 
suggests a probable spina bifida occulta. This form is not incompatible 
with a long life (Fig. 17). 

Symptoms. — A tumor is always present at birth, and is usually 
tense and fluctuating. It is either directly in the median line or slightly 
to the side of this line. The skin covering the tumor may be well 
nourished or atrophic. The usual location is in the lumbosacral 
region; it may attain a very large size if the skin covering is healthy. 
If, however, the skin covering is thin, rupture and early death generally 
result. 

All the varieties of spina bifida contain fluid which may be, at least 
partially, returned to the spinal canal by gentle, continuous pressure; 
if the sac is relaxed and soft, any contents may be clearly and firmly 
compressed and possibly outlined. The tension within the sac is often 
increased by holding the child in the upright position, especially if 
it kicks and screams. If the tumor is translucent it may be largely 
reduced, and if no central mass is palpable it points to the absence of 
any prolapsed portion of the spinal cord. Untreated cases sooner or 
later develop infection of the skin covering the sac, with subsequent 
spinal meningitis and death. Ulceration of the skin may take place, 
with rupture of the sac, the rupture healing, but again breaking open, 
and finally death from infection results. Paralysis, as it depends 
upon the amount of injury done to the cord or the existence of the 



102 CONGENITAL MALFORMATIONS 

cord in the tumor, is rarely present in spinal meningocele. In a cervical 
tumor paralysis is rare, being much more common in the lumbosacral 
forms. Paralysis, to a certain extent, depends upon tile location of 
the tumor; if low down in the sacral region and only the cauda equina 
is involved, the bladder and rectum may escape, and the legs be only 
partially paralyzed. A very small spinal opening may occasionally 
be closed by inflammatory exudate, resulting in a spontaneous cure; 
this, however, occurs so rarely that it is not to be expected. 




Fig. 17. — Spina bifida occulta. 

Trophic* changes, as shown by ulceration, are not uncommon. 
Motion and sensation may be normal or disturbed in the legs, and 
incontinence of urine or feces may be present. Other deformities of 
the body are not uncommon. A depression marks the centre of the 
myelocystocele, and the fissure in the entire vertebral column is 
usually palpable. 

Diagnosis. — The different forms of spina bifida are difficult to 
diagnose but the location of the tumor is of some assistance. A menin- 



ATRESIA OF THE VAGINA, LABIA, AM) URETHRA 103 

gocele is apt to be translucent and pedunculated, and shows no evidence 

of spinal fissure; it is important to differentiate this form on account 
of the better results following operation Myelomeningocele is apt 
to be associated with paralysis, a depression exists in the centre of the 
tumor, it has a broad base, and on palpation the bony fissure can usually 
be distinctly felt. The tumor is rarely large, and is not apt to be 
pedunculated. Myelocystocele is the form most apt to be asso- 
ciated with hydrocephalus, and pressure upon the anterior fontanelle 
increases the size of the tumor. 

Prognosis. — The prognosis varies according to the character of the 
contents of the tumor, and the integrity of its skin covering. In 
spinal meningocele operation offers a reasonable hope of cure, provided 
hydrocephalus does not exist. In other forms, if there is associated 
paralysis or hydrocephalus, the prognosis is grave, although the 
existence of paralysis does not necessarily contra-indicate operation. 
Hydrocephalus may develop after a successful operation. 

Treatment. — All tumors should be protected from pressure. The 
skin covering them should be kept clean, and the tumor supported 
by an air cushion or rubber ring. A healthy well-developed child 
should be operated upon, but a w r asted, atrophic infant is less able to 
bear operation. If the tumor is well covered by healthy skin, and not 
increasing rapidly in size, it is a good plan to wait until the child is 
six months old, and is better able to withstand the shock of operation ; 
at the same time, in my experience I have found it much better to 
operate at once if the infant and tumor are not receiving the best care 
hygienically and dietetically. The usual operative procedure consists 
of the excision of the sac, and a plastic operation to cover up the defect. 
Recovery as to life is very common, but paralysis or trophic symptoms 
may persist. 

In estimating the possible benefits from operative treatment, the 
results commonly depend upon the strength of the patient and the 
condition of the sac. The removal of the entire growth by ligation 
or by injections is not warranted. Paralysis does not necessarily 
contraindicate operation, as, in a few r reported cases, a cure of the 
spina bifida has followed surgical interference, and the paralysis has 
partially improved. 

ATRESIA OF THE VAGINA, LABIA, AND URETHRA. 

Atresia of the vagina is usually the result of an imperforate hymen 
or a septum. It may not be discovered until the time for menstruation 
arrives. Perforation or, if necessary, removal of a portion of the 
septum, and packing the opening with gauze is usually all that is 
necessary to effect a cure. If the condition is discovered in infancy, 
the obstruction can ordinarily be easily overcome by the passage of a 
probe and packing the opening with gauze. At this period the tissues 
are only slightly vascular and the membrane extremely delicate; 
later in life the septum becomes tougher and much more vascular. 
The labia minora may be more or less firmly adherent. Their separa- 



104 CONGENITAL MALFORMATIONS 

tion is, however, as a rule easily accomplished, and if a small piece of 
gauze is inserted between them to prevent subsequent adhesions a 
cure is quickly effected. Atresia of the urethra will, if complete, 
produce anuria. A small, blunt probe will often penetrate the thin 
membrane which, in the majority of cases, is the cause of the obstruc- 
tion, and quickly and permanently relieve the condition. A contracted 
meatus may cause difficult and slow micturition with tenesmus. The 
meatus may be dilated, or it may be enlarged by a slight incision. 

HYPOSPADIAS AND EPISPADIAS. 

Hypospadias. — Hypospadias is caused by arrested development in 
the corpus spongiosum. In this developmental process the urethral 
groove becomes a canal, and if the fusion of the portions necessary to 
form it be imperfect, an opening is left at some point in its lumen. 
The most common seat for this deformity is at the base of the glans, 
the defect appearing in the lower portion of the urethra and the 
adjacent part of the corpus spongiosum. The arrest of development 
occurs at or before the fourth month of intra-uterine life. If the 
urethra opens at the base of the glans, it is called glandular hypo- 
spadias; if between the scrotum and the glans, it is called penile hypo- 
spadias; and if behind the scrotum perineal hypospadias. In the 
latter the scrotum, and even the perineum, may be fissured, and if the 
testes are in the abdominal cavity the sex of the infant may be tem- 
porarily in doubt. In many cases there is more or less difficulty in 
micturition; in others control of the bladder seems to be normal. The 
treatment is purely surgical. The operation is a delicate one, but in 
the hands of a skilful specialist the result is often quite satisfactory, and 
the patient's condition is usually much improved. The most suitable 
time for the operation is when the child is four or five years old. 

Epispadias. — Epispadias is due to an arrst of development occurring 
in the same manner as in hypospadias. In this condition the urethra 
opens on the dorsum of the penis; there is a defect in the upper wall 
of the urethra, and the adjacent portion of the corpus cavernosum. 
Epispadias is a very rare condition; hypospadias is quite common. 
Exstrophy of the bladder may be associated with epispadias; persons 
with this condition are apt to be depressed mentally, and to suffer 
from incontinence of urine, the dribbling of which produces excoriation 
of the skin and causes a most disagreeable ammoniacal odor; infection 
of the urethra and cystitis are not uncommon complications. The 
treatment is, of course, purely surgical, although local applications will, 
to a certain extent, relieve the irritation caused by the dribbling of 
urine. The operation should be attempted only by a specialist, as it 
is a very delicate and difficult one ; but, in view of the almost constant 
nervous and depressed condition caused by the continuous dribbling 
of urine, it is only proper to give the child an opportunity to be 
benefited by surgical treatment. The results of operation are fairly 
satisfactory, and the best time for it to be performed is when the 
child is six or seven years old. 






CHAPTER VII. 
DISEASES OF THE NEWBORN. 

GENERAL PARALYSIS OF THE NEWBORN. 

Prenatal Paralysis. — Etiology. — Prenatal paralysis includes all those 

cases in which the paralysis, or the cause of the paralysis, develops 
before the onset of labor. Consequently it comprises all cases of 
defective cerebral development, such as porencephalia, microcephalus, 
brain atrophy, congenital cysts, and all brain lesion> of such a nature 
as to cause paralysis at birth, or some mental or physical defect that 
shows itself, perhaps, months or years after birth; also agenesis 
corticalis, in which one finds defective development of the cellular 
elements of the brain cortex more or less widely distributed, but 
especially marked in the pyramidal cells. The origin of the paralysis 
is always intra-uterine, the lesion is prenatal and occurs before labor 
begins. 

If the mother while pregnant suffers from any severe systemic 
disease, has uremic convulsions, or sustains a severe blow or fall 
on the abdomen, this form of paralysis may be induced. Arrested 
development of the brain is undoubtedly responsible for some of the 
cases, and syphilis, insanity, alcoholism, and pyogenic infections in the 
parents are supposed to be more or less effective in a small percentage 
of the patients, while secondary degeneration in the lateral columns 
of the cord is noted in a considerable number. 

Symptoms. — The symptoms are, of course, in proportion to the extent 
of the lesion. They may at birth be very mild, and only the slightest 
impairment of the mental power and gait be present ; usually, however. 
the paralysis is marked at birth, is spastic in type, and associated with 
great mental deterioration, the patient being commonly a helpless and 
hopeless invalid. 

Diplegia and paraplegia are usually present, although hemiplegia 
also may occur. The child may be microcephalic, or show evidences 
of cranial or facial asymmetry with arched palate and the stigmata of 
degeneration. 

Prognosis. — This depends upon the extent of the brain lesion or the 
extent of the lack of brain development. Most cases are very little 
benefited by treatment. In the mildest cases something may often be 
accomplished by judicious feeding, good hygiene, massage, and 
electricity. 

Treatment. — The infant should receive all possible care dietetically 
and hygienically. Its general nutrition should be kept at as high a 
level as possible, and every effort should be made under instructions 
from the mother or trained assistant to develop whatever brain capacity 



106 DISEASES OF THE NEWBORN 

the child may possess. Many patients are best cared for in institutions, 
where the results of treatment are often remarkably good. Slight 
gastro-intestinal disturbances may cause a marked temporary increase 
in the nervous symptoms, and it is, therefore, important to map 
out for these children such a diet as they can easily digest. To control 
convulsions, and possibly with the hope of preventing them, the 
bromides and iodides can be used. Iodides internally and mercury by 
inunction have been recommended. 

Natal Paralysis. — Etiology. — Natal paralysis includes all those cases 
of paralysis in the newborn in which the lesion takes place either during 
labor or immediately after birth. Hemorrhage, meningeal in origin, 
is the cause in a great majority of the cases, and is usually induced by 
a tedious labor, a difficult forceps delivery, or a breech-presentation. 
The fact that birth palsies are most common in firstborn children 
suggests that labor is the cause. Meningoencephalitis, followed by 
degenerative changes in the cortical motor area or other portions of the 
brain, is among the conditions found. The meningeal hemorrhage that 
produces the paralysis may be a part of the bleeding in hemorrhagic 
disease of the newborn. The hemorrhage may occur in the brain 
substance, it may be at the base of the brain in the cerebellar region, 
or in the region of the occipital lobes of the cerebrum, or at the con- 
vexity. It may be profuse or slight, diffused or localized, and the 
blood may come from the pia, the cerebral veins, or a sinus. In still- 
born children, hemorrhage is often found in the upper membranes of 
the cord. A few cases have been reported as the result of premature 
birth, and asphyxia is a recognized cause. Secondary sclerosis and 
atrophy may develop and involve large areas of the brain, followed 
by secondary degenerative changes in the cord, especially the lateral 
columns. 

Symptoms. — Asphyxia and paralysis are, as a rule, present at birth, 
or appear within the first twelve hours after birth. Convulsive twitch- 
ings and paralysis may not, however, develop until several days 
after delivery. Bulging of the fontanelle and slow pulse are suggestive 
of cerebral hemorrhage, and nose bleed or blood in the pharynx are 
common symptoms. A slight lesion is often unnoticed at birth, and 
remains unobserved until the child is some months old, when its failure 
to take notice, to creep, to walk, to talk, and otherwise to develop 
normally forces itself upon the attention of the parents, and a physician 
is consulted. It may not walk until almost two years of age, and 
then the gait is very unsteady. Mental development is slow, and in 
early infancy acute attacks of weakness associated with cyanosis may 
occur. If not seen early by the physician, such cases are apt to be 
ascribed to convulsions occurring, perhaps, months after birth, the 
convulsions being really due to the injury at birth, and merely a 
symptom of the progressive changes following the birth lesion. 

Athetoid movements, if present, will suggest the brain origin of 
these cases, and epilepsy as a later condition is very common. The 
convulsions often begin in the paralyzed limb and spread over the 



GENERAL PARALYSIS OF THE NEWBORN 107 

entire body, and may be associated with opisthotonos. If the lesion 
is extensive convulsions are common, and paraplegia and diplegia 

develop early, with eoma and possibly early death. 

The symptoms may be merely those of a slight monoplegia or none 
at all may be noticed by the parents; later a physician is consulted 
because the child is backward. An examination of the child may now 
reveal strabismus, poor gait with slight spasticity and exaggerated 
knee-jerks, and backwardness in walking and talking. The history 
of the birth is often one of prolonged and difficult labor. 

Where convulsions occur, they may be limited to the arm or face, 
or, after beginning in one portion, may involve the re,st of the body. 
Slow and irregular respiration is suggestive of an intracranial hemor- 
rhage, as are also a slow, weak pulse and increased reflexes. 

These patients may show nystagmus and change in the pupils. 
Convulsions are especially apt to be associated with a cortical lesion. 
After the spastic condition of the arm or leg has lasted for a few days, 
hemiplegia or diplegia may appear. If the convulsions develop within 
the first few days of life, they quite commonly cease when the child is 
two weeks old, only, however, to reappear after an interval of one, 
two, or three months. During this intervening period the myelin 
sheaths of the pyramidal tracts are developed, and in consequence a 
communication between the brain and cord is establshed which results 
in a spastic hemiplegia and a return of the convulsions. 

The fact should be noted that no matter what the character of the 
symptoms at the onset, spastic paralysis commonly develops, the 
paralysis being usually most marked and persistent in the arm. The 
extent of the paralysis may vary from complete loss of power to a 
loss so slight that it is manifested, perhaps, only after prolonged 
exertion. If at birth the child is drowsy or dull with irregular respira- 
tion, the hemorrhage is probably profuse, and the child is apt to die 
within the first twelve to thirty-six hours. If the child is born dead, 
the hemorrhage is usually extensive and is apt to be at the base of the 
brain. If the child is asphyxiated at birth, the prognosis is better if it 
can be made to breathe without much difficulty, and is able to nurse 
within the first few hours. 

Diagnosis. — Mild cases affecting one limb may suggest Erb's palsy 
or an anterior poliomyelitis ; the latter usually affects groups of muscles 
in a limb, but not an entire limb. Reflexes are absent; the limb is 
flaccid with marked wasting, the reaction of degeneration is present, 
but there is no mental impairment. Poliomyelitis comes on a con- 
siderable time after birth, and is usually preceded for from twenty-four 
to forty-eight hours by a more or less definite group of symptoms. 

In natal paralysis convulsions are common, mental impairment is 
often noted, the reflexes are increased, and a spastic paralysis may be 
present. The paralysis is apt to be paraplegia, diplegia, or hemiplegia, 
but rarely monoplegia. Athetoid movements may be noticed. 

Prognosis. — The prognosis depends upon the location and extent 
of the injury, and the degenerative changes that follow. It may vary 



108 DISEASES OF THE NEWBORN 

from the slightest loss of mental power with trivial paralysis to idiocy 
with extensive paralysis. 

Treatment. — The skilful handling of difficult labor cases is impor- 
tant, and when to apply and when not to apply the forceps is often 
a difficult question to decide. As soon as the child is born, its head 
should be raised and kept elevated and a small ice-cap applied with the 
hope of at least preventing further hemorrhage. The bowels should be 
thoroughly moved, and the child kept absolutely quiet. 

If convulsions are frequent and severe, bromide of soda, 5 grains, 
with chloral hydrate, \ grain, should be given every two or three 
hours by the mouth or rectum, and continued as long as the symptoms 
persist; or chloroform may be given cautiously by inhalation. If 
possible the general health of the child should be kept up, and especial 
attention be paid to the nutrition of the paralyzed part, every possible 
endeavor being made to prevent contractures. The best of food, 
abundance of fresh air, massage, and passive exercises are all of 
advantage. 

Braces may be of assistance, and lengthening, cutting, and trans- 
planting of tendons may be necessary. Short school hours should be 
the rule for these children; if nervous and highstrung, school attend- 
ance should be, at least temporarily, given up. 

If the position of the clot can be accurately determined by localized 
convulsions or paralysis, a surgical operation should be performed for 
its removal, especially in those cases where, in spite of medical treat- 
ment, alarming symptoms continue. The difficulty, of course, is to 
locate the clot accurately. Medical literature now records a number 
of instances where the operation has been successfully accomplished. 
If a meningeal hemorrhage is diagnosed, and the anterior fontanelle 
is bulging, puncture of the fontanelle may be performed at once with 
the hope of drawing off some of the blood before it clots. A needle 
is introduced to a depth of one-sixth to one-fourth of an inch, as far 
from the longitudinal sinus as possible, and an attempt made to with- 
draw some of the effused blood. If any blood is secured, the procedure 
is of value, both in a curative sense and as a means of diagnosis. 

BIRTH PALSIES. 

Erb's Palsy {Obstetric Paralysis). — This form of palsy was first 
described by Duchenne, and later more carefully studied by Erb. 
The condition is due to an injury of the brachial plexus at birth. It 
may be caused by pressure from the application of the forceps, or 
during labor by a contracted pelvis. It is especially common in 
breech presentations, rarely occurring in a spontaneous delivery. It 
may be the result of traction in the axilla during delivery, or upon the 
shoulder, traction necessarily being employed in order to deliver the 
after-coming head; the injury may also be produced in bringing 
down the arms which are extended above the head. The lesions consist 
of a stretching and tearing of the nerves, and, to a certain extent, of the 



BIRTH PALSIES 



101) 



surrounding tissues, which result in a localized area of inflammation, 
and possiblv subsequent degeneration. 

Symptoms. — The symptoms may be severe, or they may be very 
slight. The loss of power in the arm may be noticed immediately at 
birth, or, in mild cases, not for some weeks. The arm may hang limp 
and helpless without any power of motion at the shoulder. In old 
cases it is often noticed that the shoulder tends to drag lower than 
that on the healthy side. The nerves usually injured are the fifth 
and sixth cervical. According to Erb, a lesion at the spot where the 
sixth cervical passes between the scalenus muscles will produce the 
classical symptoms of Erb's palsy. The paralysis affects, wholly or in 
part, the deltoid, biceps, supinator longus 
and brevis, supra- and infraspinatus, 
and the brachialis anticus. The upper 
arm is rotated inward; the forearm is 
pronated, and the palm is turned more 
or less outward. Supination at the elbow 
is absent and motion at the wrist-joint is 
normal with the possible exception of more 
or less loss of extension. Flexion is always 
normal at the wrist. The forearm is 
not affected. The hands may be normal 
or show a slight loss in power of flexion. 

There may be disturbance of sensa- 
tion on the outer surface of the arm 
in those portions supplied by the mus- 
culocutaneous nerves and the axillary 
nerve. The sensibility of the inner sur- 
face of the arm remains normal. If the 
child does not tend to recover, trophic 
changes develop, contraction of the af- 
fected muscles takes place, and the 
shoulder blades become prominent. The 
bones of the arm fail to grow normally, 
and subluxation of the shoulder which 
tends still further to interfere with motion 

may develop. A fracture of the clavicle or humerus, or a separation 
of the epiphysis of the upper end of the humerus, is a complication 
which is occasionally found at birth and renders the diagnosis and 
prognosis of Erb's palsy more difficult. 

Diagnosis. — An old case of Erb's palsy, seen for the first time, may 
simulate anterior poliomyelitis. Erb's palsy develops at birth or soon 
after, and infantile paralysis always at a considerable period after 
birth. Subluxation of the shoulder is suggestive of Erb's palsy, 
and the group of muscles affected in Erb's palsy is not often found 
affected in infantile paralysis. Paralysis due to syphilis can be differ- 
entiated by the history and other evidences of syphilis. The inward 
rotation of the arm resulting from a separation of the upper epiphysis 
of the shoulder can be diagnosed by the .r-rays. 




Fig. 18. — Erb's palsy. 



110 



DISEASES OF THE NEWBORN 



Prognosis. — The fewer the muscles involved and the earlier the 
treatment is begun, the better the prognosis. Most cases recover 
entirely, although a few in spite of treatment show little or no 
improvement. 

Treatment. — If the muscles respond to faradism rapid recovery 
often results, and the affected muscles should be treated with faradism 
every day, provided they respond; if they do not respond, galvanism 
should be employed. Daily massage will improve the nutrition of the 
parts, and tends to prevent the development of contractures. For 
those patients who have been treated faithfully and systematically 
by massage and electricity for some months without benefit, a plastic 
operation on the injured nerves and tendons is worthy of consideration ; 
in a few cases, quite satisfactory results have followed the suturing 
of the involved nerve trunks. 



TO SCALENI & 
LONGUS COLLI 



POSTERIOR 
THORACIC 



-FROM FOURTH CERVICAL 



LEVEL OF THE 
CLAVICLE 




SUPRASCAPULAR 

XTERNAL ANTERIOR THORACIC 



INT ERNAL ANTERIOR THORACIC 

9f,. 



MUSCULO SPIRAL 



THIRD S;-^ 



L CUTAN 



E ou s ~"~~- 



Fig. 19. — Plan of the brachial plexus. (Gerrish.) 



Klumpke's Palsy. — In contradistinction to Erb's palsy, or the upper 
arm type, is the form described by Klumpke and called the lower 
arm type. The muscles involved in this form are those innervated 
by the seventh and eighth cervical and the first dorsal nerves. These 
muscles may be the only ones involved, or, in addition, those supplied 
by the fifth and sixth cervical nerves may also be affected. 

Symptoms. — A single muscle, as the deltoid, may be affected, or 
all the muscles of the arm may be involved, and the entire arm 
and hand may be more or less completely paralyzed with loss of 
sensation. In certain cases, in addition to the muscles involved in 



ALBUMINURIA AND URIC ACID INFARCTION 111 

Erb's palsy, the subscapularis, rhomboideiis, serratus and pectoralis 
major may be affected. The lesion is occasionally bilateral. Eye 
symptoms are present, due to the involvement of the sympathetic 
nerve from the first dorsal; the latter connects with the lower portion 
of the brachial plexus (Fig. 19). 

The opening between the eyelids is narrow, and a contraction of the 
pupil is present which, however, reacts well to light and accommo- 
dation. The prognosis and treatment are the same as in Erb's palsy, 
as the lesions are identical, but different nerves are involved. 

Facial Palsy. — The paralysis may be on one or both sides, is periph- 
eral in origin, and may involve one or more of the branches of the 
nerve. It is usually seen in children delivered by forceps, when one of 
the blades has pressed firmly on the facial nerve, producing an injury 
to the nerve sheath and the nerve fibers. It may also follow delivery 
in cases of contracted pelvis. The prognosis is usually favorable, 
all traces of the paralysis disappearing, as a rule, in the first few 
months of life. 

ALBUMINURIA AND URIC ACID INFARCTION. 

Albumin in the form of nucleo-albumin is found in the urine of the 
majority of infants at birth, but never in large amounts. As a rule 
it persists for from one to ten days, although it may occasionally 
continue for a month. 

During the first few days of life infants take only small amounts of 
liquids in the form of breast milk and water, but eliminate con- 
siderable fluid by the skin and breath which tends to lessen the amount 
of urine voided, and during this period of slight urinary secretion 
albuminuria and uric acid infarction are apt to appear. That these 
have some connection with the quantity of fluids ingested is shown by 
the fact that they are much less common in bottle-fed babies who 
invariably receive a larger amount of food during this period than 
those fed at the breast. 

The urine voided immediately or soon after birth is normal, and 
the kidneys of stillborn infants rarely show uric acid infarction. 
These infarcts of uric acid are, however, often found in the kidneys 
of children a few days or weeks old, and consequently must develop 
after, and not before birth. 

The same rule as to time is noticed in the microscopical findings. 
Normal at birth, in a day or two the urine becomes cloudy and contains 
hyaline and epithelial casts, leukocytes, and epithelium from the 
kidney. The casts are found much more commonly in breast-fed 
(40 per cent.) than in bottle-fed (10 per cent.) infants. The brick- 
dust stain on the diapers during the first few days is caused by urates. 
These urinary findings are all apparently due to uric acid infarcts in 
the kidneys, and are, as previously mentioned, largely dependent 
upon the amount of water and milk ingested during the first few days 
or weeks of life. 



112 DISEASES OF THE NEWBORN 

It is a question whether it is physiological for albuminuria and casts 
to be present in the urine of the newborn. The nucleo-albumin must 
be due to a disturbance of the kidney function; it cannot come from 
the blood since nucleo-albumin does not exist in the blood. 

BONE INJURIES. 

As a result of injury during a difficult labor, the bones of the infant 
may be more or less seriously injured. This is more commonly seen 
in the bones of the skull, where depressions and fractures may follow 
the use of the forceps, although the same conditions may be found 
when no instruments have been used. The parietal bones are the ones 
most often injured; but, unless the underlying membranes and brain 
tissues have been affected, the injury may, if not excessive, be produc- 
tive of little or no harm, the bones tending to assume their normal 
relation as to shape with the gradual development of the head. If, 
however, a hemorrhage has occurred beneath the skull — inside the 
cranium— coma, convulsions, subsequent epilepsy, or death may result. 

In breech presentations the lower jaw may be fractured by unneces- 
sary traction. A fracture of the clavicle and humerus, or a separa- 
tion of the epiphysis of the humerus, may result from the difficulty 
in bringing down the arm. The femur has been fractured by improper 
traction with the fingers, fillet, or blunt hook. In other cases para- 
plegia may follow an injury to the spine and cord occurring during 
labor. 

The important point which such injuries emphasize is the necessity 
of a careful examination of all infants immediately after delivery, 
and this is especially to be enjoined after all difficult labors. The 
treatment of all such conditions is, of course, surgical. 

ASPHYXIA OF THE NEWBORN. 

A healthy normal child breathes deeply almost immediately after 
birth, cries loudly, kicks vigorously, and begins at once to inflate its 
lungs. The upper lobes expand first, and the posterior portion of the 
lower lobes last, the external portions expanding before the deeper 
internal parts. At least one or two days pass before the lungs fully 
expand, and in weak infants, or those born prematurely, it may be one 
or two weeks before expansion is complete. Owing to the changes which 
occur in the atelectatic portions of the lung, full expansion becomes 
more difficult as time progresses. 

In asphyxia of the newborn the absorption of oxygen and the giving 
out of carbon dioxide are checked wholly or in part; and this condition, 
if severe, becomes extremely dangerous. 

Etiology. — If the respiratory centre is stimulated before the child is 
born, attempts at breathing are induced, and asphyxia from inhalation 
of foreign matter is the result. The stimulus to breathe may be derived 
from the mother as the result of a fall in her blood-pressure due to 
hemorrhage, protracted labor, or to her death. 



ASPHYXIA OF THE NEWBORN 113 

An abnormal form of uterine contraction, the so-called tetanus uteri, 
or any disease of the heart or lungs in the mother combined with 
poor circulation and poor oxygenation of her blood, will produce intra- 
uterine asphyxia in the child. So will any condition which causes 
compression of the umbilical cord, as early detachment of the placenta 
or premature birth, the respiratory muscles being weak and the 
respiratory centre poorly developed; or any condition like cerebral 
hemorrhage, which produces abnormal intracranial pressure. As the 
carbon dioxide in the blood increases and the oxygen decrease-, the 
respiratory centre loses more and more its power to respond to stimula- 
tion, until finally no effort at respiration is made, and it becomes 
paralyzed. It is, however, apparently more the lack of oxygen that 
paralyzes the respiratory centre than an increase of carbon dioxide. 

Asphyxia Cyanotica. — A child suffering from intra-uterine asphyxia 
passes meconium, and invariably shows a weakness in the heart 
sounds; if the asphyxia is extreme the heart's action become- unusually 
rapid, and the child is in danger of death, a condition which generally 
demands that labor be terminated as soon as possible. 

In asphyxia cyanotica the child's color at birth varies from a bluish 
tint to a dark blue. It lies absolutely still, its face is swollen, it- eye- 
are closed. The respirations are superficial, and the intervals between 
them may be much longer than normal. Mucous rales can often be 
heard, or felt by the hand on the thorax. The muscles preserve their 
firmness and tone, and the heart's action is strong but slow. A finger 
introduced into the pharynx to remove inspired material produces 
reflex choking. The respiratory movements can usually be increased 
with little difficulty by external applications, either hot or cold. 

^Lsphyxia Pallida. — In this form the upper air passages are more or 
less completely blocked with mucus. The infant is very pale, its lips 
are blue, and the muscles are limp and relaxed. Reflex irritation is 
abolished, the heart is rapid and weak, and the extremities are cold. 
Respiration is practically suspended, although the child frequently 
gasps for breath. The temperature slowly falls, the heart's action 
becomes more feeble, and the child may sink and die. In milder 
cases, the respiration gradually becomes better established, the eyes 
open, and the child's movements grow stronger. The skin becomes 
warm and pink, the pulse stronger and regular; coughing and vom- 
iting help to expel the mucus. The umbilical cord is soft, pale, and 
relaxed. 

Pathological Anatomy. — The right heart is distended, the blood 
watery, the liver congested. Hemorrhages into the pia, pericardium, 
pleura, and liver occur, also hemorrhagic effusions into the serous 
cavities. There is marked congestion of the lungs, and the upper air 
passages and bronchi are filled with inspired matter. If the child at 
birth has made any efforts at respiration, and has, perhaps, lived for 
a short time, areas of more or less expanded lung tissue are found, 
which are light in color and elevated above the dark and tougher 
atelectatic portions. Inspired materials, such as mucus, blood, 
8 



114 DISEASES OF THE NEWBORN 

amniotic fluid, and meconium are found in the upper air passages and 
large bronchi; sometimes also in the small bronchi. 

Prophylaxis. — Prophylaxis includes the conduct of the labor in such 
a manner as to prevent, so far as possible, the causes which produce 
asphyxia, and also such care of the mother during pregnancy as may 
protect her from infections and injuries. 

Diagnosis. — Asphyxia, either cyanotica or pallida, is evident as 
soon as the child is born. The clinical picture of either form is so 
clear that a diagnosis can be made immediately. The only question 
which may arise is, as to whether the asphyxia may be due to a cerebral 
hemorrhage instead of to some impediment in the placental circulation, 
or to material inspired into the upper air passages. iVsphyxia due to 
brain hemorrhage is associated with a bulging fontanelle, convulsions, 
irregular respiration, slow pulse, and stupor, the respirations being 
sufficiently numerous to warrant some lessening of the asphyxia. 
Asphyxia not due to brain lesions is invariably relieved by any 
improvement in the respiratory rate, except, of course, in premature 
or very weak infants, where the respirations are fairly regular, the 
asphyxia being in these cases simply an index of the child's poorly 
developed nerve centres and muscles. 

Prognosis. — If treatment is prompt and energetic, many of the 
apparently hopeless cases are saved. When the asphyxia is asso- 
ciated with any lesion of the central nervous system, mental defects 
or evidences of paralysis may develop. In asphyxia due to cerebral 
hemorrhage the prognosis, of course, depends upon the extent of the 
brain lesion. 

Treatment. — Artificial respiration must be continued in every case 
until the child breathes with sufficient regularity to make one feel 
that this assistance is no longer required. It is difficult to say how long 
one should persist in artificial respiration in apparently hopeless or 
desperate cases. Many children have been saved by this method who, 
seemingly, had little chance of life, judging by their appearance 
immediately after birth. As long as a heart beat can be detected, it is 
possible for life to be saved. 

The mucus and inspired materials that clog the upper air passages 
and bronchi must be removed as quickly as possible. The mouth 
and pharynx should be wiped out with gauze, and the deeper mucus 
removed by aspiration through a soft catheter. Alternate hot and 
cold douches are beneficial in stimulating respiration, or the child 
may be alternately plunged into hot, then cold water, always in 
asphyxia pallida beginning and ending with hot water. In this form, 
too, special efforts should be made to keep the infant's body warm, 
and the child should be carefully watched for from twenty-four to 
thirty-six hours to see that the asphyxia does not return. Inhalations 
of oxygen are of benefit in these cases, also small doses of whisky, 
10 drops every three hours, with strychnin T ^ of a grain hypo- 
dermically, repeated in six hours. 

If blood is allowed to escape from the umbilical cord a portion, 



ASPHYXIA OF THE NEWBORN 115 

at least, of the carbon dioxide is removed; and, in a few reported 
cases, this blood has been replaced with good results by transfusing 
normal salt solution into the umbilical vein. Intratracheal insufflation 
of oxygen has been performed with apparent benefit. In a doubtful 
case of cerebral injury, lumbar puncture may help to clear up the 
diagnosis; if the fluid removed is clear it points to the absence of 
hemorrhage within the skull; if blood-tinged, it indicates some injury 
to the central nervous system, and the removal of the blood-tinged 
fluid may possibly assist in the treatment. 

Atelectasis.— The lungs at birth are normally in a condition of 
atelectasis, but begin to expand at the very first breath, the upper 
portions being inflated first, and the lower parts last. It is not only 
necessary that the lungs be inflated as soon after birth as possible, 
but, once inflated, that they be kept expanded — a task not always 
easy of accomplishment in weak and puny infants. The longer the 
• time after birth that the lungs remain atelectatic, the greater the 
changes that take place in them, and the more difficult it is for the 
infant to inflate the collapsed portions. 

Etiology. — Atelectasis is often the result of the same causes as is 
asphyxia, i. e., tedious labor, premature birth, inhalation of foreign 
materials before birth, and cerebral hemorrhages. It is frequently 
seen in frail and delicate infants, and in eases of hereditary syphilis. 

Pathological Anatomy. — If a child with atelectasis lives but a day 
or two, only a small portion of the anterior borders of the upper lobe 
become expanded, and this portion may also be emphysematous. 
The posterior portion of the lower lobes is the most common seat of 
atelectasis. The unexpanded portion is brownish-red, very vascular, 
does not crepitate, and shows globular outlines on the surface and on 
section; it can very easily be inflated. Small hemorrhages are fre- 
quently found beneath the pleura. Both lungs are usually involved. 
The child may live several weeks, and yet be quite atelectatic; and, if 
the condition persists a long while, it is apt to be associated with 
pneumonia. The right heart is commonly dilated, the liver and spleen 
are enlarged and congested, and cerebral hemorrhage, either at the base 
or convexity, is often present, especially where there is a history of 
difficult labor. Lung conditions, such as aplasia, may be noted, or 
atelectasis may be associated with an enlarged thymus. Delicate 
thoracic walls and poorly developed respiratory muscles favor the 
non-expansion of the lung. 

Symptoms. — In atelectasis the whole or a part of the lung remains 
in the fetal state. The condition is usually associated with asphyxia, 
and in relieving the asphyxia we generally assist in clearing up the 
atelectasis to a greater or less extent. Feeble and premature infants 
do not breathe deeply enough fully to expand their lungs, and portions 
remain atelectatic. The respiratory movements are weak and apt 
to be superficial, with irregular rhythm. In severe cases of atelectasis, 
the cyanosis is generally marked. As a rule, the history is that of a 
moderate asphyxia at birth, the infant, however, being revived without 



116 DISEASES OF THE NEWBORN 

great effort. The child is below the normal weight, and frail and 
delicate, perhaps premature. It fails to gain in strength or weight, 
the hands and feet are generally cold, and the temperature may be 
subnormal. The cry is feeble. From time to time, there are evidences 
of cyanosis which may be slight or marked; it may develop suddenly 
without apparent cause and be extreme, even ending fatally, con- 
vulsions often appearing before death. 

It must be borne in mind that an atelectatic child need not neces- 
sarily have been asphyxiated at birth. The child may present no lung 
symptoms until the final attack of cyanosis develops. Many of the 
cases occur in puny delicate infants, or the prematurely born, with 
low vitality, and an improvement in the atelectasis is an indication of 
improvement in their general health. If the child gains in weight 
the atelectasis gradually disappears. Often an excess of carbon dioxide 
— either small or great, but persistent — is present in the blood, while 
the amount of oxygen is subnormal, thus causing paralysis of the 
respiratory centre. The infant is unnaturally quiet, often drowsy, 
the face and hands may be puffy, and the temperature perhaps sub- 
normal. Breathing is irregular and slow, and on crying a few rales 
are heard at the back and base of the lungs. Attacks of cyanosis, 
mild or severe, may develop without apparent cause or warning, and a 
premature child several weeks of age may suddenly become cyanotic, 
and develop dangerous symptoms, and even death follow. In the most 
severe cases asphyxia is marked at birth, the child is only partially 
revived, lives a few days or hours, and dies with all the evidences of 
asphyxia, prostration, and coma. 

Diagnosis. — Atelectasis is most common in the posterior portion 
of the lower lobe of the lung. Over this portion resonance is impaired, 
but, as the collapsed areas are surrounded by portions of inflated 
lung, the impairment is not marked, the respiratory murmur is feeble 
and harsher than normal, and on deep inspiration rales are usually 
heard. The cardiac sounds may be transmitted more clearly than 
is normal. 

Prognosis. — This depends on the cause and the treatment. If the 
child improves, as shown by a gain in weight, strength, and vitality, 
the chances are good. If the cyanosis tends to recur, with loss of 
flesh and vitality, a subnormal temperature, and cold hands and feet, 
the prognosis is grave. 

Treatment. — A frail and delicate infant, especially if drowsy and 
with irregular respirations, must be aroused five or six times a day. 
Its face may be washed with hot and cold water alternately, or may 
be sharply smacked with a handkerchief dipped in cold water, or 
the abdomen may be slapped in a similar manner. If possible, the 
infant must be made to cry and to take deeper, fuller breaths. The 
temperature can be maintained with hot water bottles, and the 
cyanosis combated with oxygen inhalations. Excessive handling is 
bad for babies; but a certain amount of it is beneficial, especially 
if the baby is frail and delicate. Pick it up, rub it, change its position 



MASTITIS 117 

From one side to the other. If allowed to lie a long time in its crib, 
as is occasionally the ease in asylums and hospitals, a feeble delieate 
child is apt to develop atelectasis, and certainly recovers from it with 
difficulty. The cold hands and feet should be protected with mitts 
and socks. Breast milk is by far the best food; the breast may be 
pumped out, and the milk fed to the infant with a dropper, a spoon, 
or a Breck feeder until the baby is strong enough to nurse. In order 
to keep up the mother's secretion of milk, another infant should, 
if possible, be put to the breast. For relief of the cyanosis artificial 
respiration, warm baths, whisky internally, and oxygen by inhalation 
are recommended. 

MASTITIS. 

There appears in all children two or three days after birth a swelling 
of the mammary glands, which increases gradually, is more marked 
in s.ome infants than in others, and reaches its height at about the 
tenth day, then slowly subsides, and disappears in the third week. 
The condition is physiological, and produces no symptoms, so far as 
we can judge. According to J. Halban, it is caused by the presence in 
the fetal and infant blood of certain bodies that exist in the blood of 
pregnant women, and are carried by the placental circulation to the 
blood of the fetus. At birth these bodies are present in the blood 
of all children, boys and girls, and they reappear in girls at puberty, 
and in women during pregnancy. Halban claims that they are pro- 
duced by placental and chorion secretions, and that the swelling which 
normally appears in the breasts of the newborn infant is due to the 
temporary existence in the infant's blood of these bodies, and that 
the same secretion in the blood of the mother stimulates the marked 
changes that occur in her mammary glands. The infant's breasts 
after birth show distended ducts, hemorrhages, leukocytes, and 
proliferated epithelium — products similar to those in the breasts of 
its mother. The baby's breasts are enlarged, more or less firm, and on 
gentle pressure a few drops of milky fluid can be expressed. This 
fluid, chemically examined, contains fat, milk sugar, protein, salts, 
and ash. Microscopically it shows milk globules, leukocytes, and 
colostrum corpuscles, and in composition it is practically the same as 
colostrum. Mastitis developing in this physiologically enlarged breast 
manifests itself by enlargement, with redness and tenderness. The 
swelling gradually increases, and unless checked may go on to abscess 
formation. Loss of sleep, crying, and restlessness, with vomiting and 
diarrhea, are the usual symptoms, and high fever is common. 

Etiology. — Squeezing or pressing the breast to express the milk is 
probably the most common cause of mastitis, and a binder, if applied 
too tightly, may by its continuous pressure produce the same result. 
The tendency to inflammation is, of course, increased by the physio- 
logical activity and congestion normally present, particularly during 
the second week of life, when it is greatest. The skin of the newborn 



118 DISEASES OF THE NEWBORN 

is liable to infections through the slightest injury, hence organisms 
effect an easy entrance. 

Bacteria are normally present in the milk ducts of infants, and any 
local condition which lowers the resistance of the epithelium permits 
the migration of these bacteria with resulting inflammation. Any 
abrasion, crack, or injury to the infant's nipple, such as might result 
from a too vigorous washing and first cleansing of the infant, can 
easily become the portal of entry for the invading bacteria. 

A child's body should always be kept absolutely clean, and want of 
care, as a rule, is probably a common cause for the development of the 
condition. In the girl baby, suppuration will necessarily produce 
more or less destruction of normal glandular tissue, and this will 
interfere to a greater or less extent with the future normal development 
of the breasts. 

Prognosis. — A mild attack of mastitis is not apt to make the infant 
ill; if, however, the inflammation spreads and becomes phlegmonous, 
as it may in a delicate and frail infant, the condition may be serious. 

Treatment. — Prophylaxis comprises the protection of the breasts 
from pressure and trauma, and the observance of absolute cleanliness. 
It is never wise to attempt, even in the gentlest way, to squeeze out 
the milk normally present. The breasts should be carefully protected 
from unnecessary pressure and manipulation. If inflammation ap- 
pears a pad of gauze, kept wet with alcohol one part to three parts of 
water, and covered with oiled silk, should be continuously applied to 
the inflamed area and kept in place by a loose, broad bandage. 

The infant's food should be diluted by giving it a tablespoonful 
of water before each nursing, and its bowels moved by a dessertspoon- 
ful of castor oil. If pus forms, an incision should be made parallel 
with the direction of the milk ducts, and a suitable antiseptic dressing 
applied. The incision should be made near the periphery of the gland 
in order to cut as few milk ducts as possible. Treatment is usually 
successful, and the abscess heals in a few days. The suction apparatus 
of Bier may possibly be of service. 

ICTERUS NEONATORUM. 

Etiology. — This form of jaundice occurs in the newborn and is 
considered physiological ; so far as is known at present it is unconnected 
with any pathological condition. Undoubtedly it is in some way 
associated with the liver, and, while there are many theories as to its 
origin, it is probably due to an active production of bile immediately 
after birth; this, added to the fact that the capillary bile ducts are 
filled with viscid bile before birth, produces distention of the capillaries 
in excess of their emptying capacity, and this excess of bile is absorbed 
by the blood. The disintegration of the maternal erythrocytes is 
also to a certain extent concerned in the production of the jaundice. 

Pathological Anatomy. — The liver is found to be only slightly 
jaundiced in small areas. The kidneys and spleen are normal, and the 






ICTERUS NEONATORUM 119 

color of the stools is unaffected by the icterus. Macroscopically the 
urine dot's not show the presence of bile, although delicate tests may 
reveal bile pigment, bilirubin, and glycocholic acid. In a case of 
icterus neonatorum death must, of course, be caused by some fatal 
disease or condition unconnected with the icterus. 

In such instances, according to Orth, bilirubin crystals are found 
in the kidneys, in the blood, fatty tissues, brain, and other organs. 
With the exception of the spleen and kidneys almost all of the organs 
and tissues are jaundiced, and this is especially marked in the serous 
membranes, the intima of the bloodvessels, and the exudates and 
transudates. The bile ducts are normal. 

Symptoms. — Jaundice appears between the second and fifth days 
after birth, occasionally later. It is usually first seen on the face, and 
then spreads over the entire body. The hyperemia normally present 
in the skin may obscure the jaundice for the first twenty-four hours 
after its appearance, but pressure on the skin makes the icterus easily 
recognizable. The sclerotic coat of the eye is usually but not always 
yellow, and the mucous membrane of the mouth is also jaundiced, 
as is shown by the yellow tint which appears after firm pressure upon 
the buccal mucous membrane. The pulse rate is normal in the infant 
with icterus neonatorum, and this is also true of older children with 
jaundice, probably owing' to the fact that only small amounts of the 
biliary acids are found in the bile of children; according toJakubowitsch 
glycocholic acid is present but taurocholic is not. The icterus may be 
slight or very intense; it usually persists for from four to eight days, 
although it may last only for two days, or may continue for three weeks. 

If, after two or three weeks, the jaundice shows a tendency to persist 
or to deepen, it is unlikely that the disease is merely icterus neonatorum, 
but it is probably a more serious form, the result of either sepsis or 
obliteration of the bile ducts. The condition is very common; if 
carefully examined over 50 per cent, of all children will show more or 
less evidence of it. It is especially common in premature children, 
and the smaller the birth weight the more intense is, as a rule, the 
jaundice. It is claimed that it occurs more frequently in the children 
of primipara than of multipara, and early ligation of the umbilical 
cord is said to lessen the liability of its occurrence. It is probably a 
physiological condition which, so far as is known, does not permanently 
harm the child, although it is claimed that children deeply jaundiced 
are especially apt to lose weight during the first few days of life, and 
their subsequent gain is slower. The urine is usually normal in appear- 
ance, but is said to contain increased amounts of urea and uric acid. 
The jaundice has no effect on the color of the stools. 

Diagnosis. — Jaundice associated with sepsis does not appear until 
after the fifth or sixth day, it is accompanied by fever and loss of 
weight, and often by umbilical infection, pneumonia, meningitis, 
peritonitis, or epiphysitis. Cases with congenital malformations of the 
bile-ducts are usually, but not always, jaundiced at birth. The icterus 
steadily deepens, there is no bile in the stools, the urine is high-colored, 



120 DISEASES OF THE NEWBORN 

and the symptoms continuously increase in severity until death occurs. 
I lemorrhages under the skin and in the mucous membranes are common. 
In interstitial hepatitis, which may be syphilitic, the liver and spleen 
are enlarged, and the jaundice is usually more intense than in icterus 
neonatorum. Gall-stones are rare in children, but are more common 
in infancy than during child life. Still reports 15 cases in infants, 
in several of whom the jaundice was marked at or soon after birth, 
and gall-stones were found in the ducts. In catarrhal jaundice icterus 
of the conjunctiva is noted as the first symptom before there is any 
evidence of jaundice in the skin. The urine is invariably high-colored. 

Prognosis. — This form of jaundice in itself js never dangerous, but 
a coexisting condition, such as premature birth or atelectasis, may 
of course influence the prognosis. 

Treatment. — The disease requires no special treatment, and, if no 
complications arise, is self -limited. Care as to diet, fresh air, and 
general hygiene is important in all well-marked cases of jaundice in 
infants, owing to the fact that the child may be premature, and have a 
tendency to regain the initial loss in weight more slowly than those not 
affected with icterus. 

ACUTE SEPTIC INFECTION OF THE NEWBORN. 

This includes all acute infections in the newborn produced by 
bacteria. The infection may be local, as in the eye, mouth, umbilicus, 
and vagina, or bacteria may enter the circulation and produce a severe 
or fatal septicemia or pyemia. 

Etiology. — Septic infection of the newborn was formerly common 
in large maternity hospitals, and to a less degree in private practice; 
but as a result of the general adoption of asepsis the number of cases 
has largely decreased. The newborn infant is especially liable to 
infection owing to the open wound at the umbilicus, and to the 
abrasions of the skin and mucous membranes which may happen at 
birth. Moreover, its power of resistance to infection is very slight, 
the inability to resist or cast off septic infections being probably due 
to the lessened antibodies and other protective substances in the 
blood, as well as to the comparatively undeveloped condition of the 
lymphatics and spleen. 

Breast-fed babies are less liable to, and resist, infection better 
than bottle-fed babies, the vital principles of breast milk probably 
being one of the factors contributing to this result. Frail and prema- 
ture infants, too, are not only more susceptible to septic infection but 
less able to resist its progress. The infection in the large majority of 
cases comes from without ; the main portals of entry are the umbilicus, 
the skin and mucous membranes, and the respiratory and gastro- 
intestinal tracts. Many cases are umbilical in origin, even when there 
is apparently no local evidence of infection at the navel. Infection 
of the thrombi in the umbilical veins readily occurs owing to their 
proximity to the bacteria normally present and active in the necrotic 



ACUTE SEPTIC INFECTION OF THE NEWBORN 121 

processes which result in the separation of the umbilical stump. If 
septic phlebitis follows, general sepsis may develop and involve one 

or many of the organs of the body ; in these infants the liver is especially 
liable to infection because so much of the blood immediately passes 
through it. Septic infection may be conveyed through any abrasion 
of the skin or mucous membrane, or infected materials may be inhaled 
or swallowed either just before or after delivery. Sepsis may be 
produced by many different bacteria; most commonly by the staphy- 
lococcus pyogenes albus and aureus, the streptococcus, the pneumo- 
coccus, the colon bacillus, the bacterium lactis aerogenes, the bacillus 
enteridis, the bacillus pyocyaneus, or the proteus group, and, less 
often, by the meningococcus, the influenza bacillus, the gonococcus, 
and the bacillus of Friedlander. Modern aseptic treatment of the 
cord has, however, lessened the number of these cases, as the majority 
of infants are infected from external sources. 

Bacteria are often air-borne, especially in hospitals. They are 
found in breast-milk when the breast itself may apparently be normal; 
bacteria may enter the milk ducts from without through the skin, or 
an abscess, ulcer, or fissure may exist. Judging clinically, this milk 
apparently seldom in any way injures the infant. Infection is less 
likely from human than from cow's milk; bacteria are present in both, 
but are, of course, less numerous and less apt to be pathogenic in human 
than in cow's milk. 

The nurse may, perhaps, be the carrier of infection from the mother 
or from another child, or it may be carried by the physician by means 
of instruments, dressings, or unclean hands. Soiled clothing and 
dirty bathing water are not infrequent sources of infection through the 
injured or normal skin of the infant. The bathing of infants before 
the navel has healed apparently increases the chances of infection. 
Of 1420 infants tubbed during the period preceding the healing of the 
umbilicus, infection occurred in 18 per cent., whereas in 1692 infants 
not tubbed only 8 per cent, were infected. 

The epithelial lining of the gastrointestinal and respiratory tracts 
in the infant offers little resistance to the invasion of bacteria and, 
as has been previously stated, the baby's ability to produce antibodies 
or protective substances is slight. Infection may come from within 
and the newborn be septic at birth, the infection occurring through 
the placental circulation. The mucous membrane of the mouth is 
also often the seat of infection. 

Pathological Anatomy.— In all severe cases hemorrhages and degen- 
erative changes take place in the parenchyma of the heart, liver, and 
kidneys. Hemorrhages occur in almost all of the organs of the body, 
as well as in the skin, the mucous membrane, and in the membranes 
of the brain, especially the dura, but only occasionally in the brain 
substance. The latter is often edematous and congested. In the 
lungs bronchopneumonia and atelectasis are often found to exist. 
and septic emboli may produce infarcts or small abscesses; while 
degenerative changes, fatty in nature, are found in Buhl's disease. 



122 DISEASES OF THE NEWBORN 

The pleura often shows a purulent or serofibrinous exudate. Multiple 
abscesses may develop in the liver. The spleen may enlarge, and in- 
flammation of the mucosa of the gastro-intestinal tract may exist. 
As a rule, the peritoneum is inflamed only in those cases where the 
infection has entered by the umbilicus. The kidneys are always 
involved, the lesion being usually either parenchymatous or fatty 
degeneration with necrosis of the renal epithelium and involvement 
of the kidney pelvis. Periostitis, osteomyelitis, and arthritis may 
be present. Umbilical phlebitis and arteritis commonly coexist with 
umbilical infection. Gastro-enteritis may also be found. 

Symptoms. — The symptoms of septic infection in the newborn vary 
greatly, according to the location of the portal of entry, the severity 
of infection, the resistance offered by the infant, and whether the child 
was born prematurely or at full term. In a large majority of cases the 
symptoms are severe and the baby seriously ill, but they may be mild 
and localized; as, for example, an inflammation in the skin or joints, or 
a slight infection of the umbilicus. Inasmuch as the symptomatology 
varies so much in different infants, a better idea of the clinical aspect 
can be obtained by studying the symptoms separately than from 
individual cases. 

Temperature. — The temperature is very variable; it may be quite 
high, only moderate, or even subnormal. No fixed temperature is 
typical. It may fluctuate between wide limits. The most common 
temperature chart is one that shows high fever, 103° to 105° F., with 
a drop each day nearly to or below normal. This continues for a 
few days, after which, with the rapidly increasing weakness of the 
child, it continues normal or subnormal with more or less irregular 
fluctuations. 

The Skin. — The skin is decidedly jaundiced, especially in umbilical 
infection, the marked changes that occur in the blood being a factor 
in its production. Cyanosis may be noted in the lips, hands, and 
feet, and there may be swelling of the feet and pretibial edema. 

Hemorrhages. — Hemorrhages are very common, and form a dis- 
tressing and dangerous symptom. They may occur from the umbilicus, 
bowel, stomach, or any mucous surface, or may be noted as large or 
small purpuric rashes in the skin. Large areas of skin may undergo 
necrosis as a result of infection from without, while a deeper necrosis 
may produce extensive bed-sores. 

The Mouth. — Inflammation, either deep or superficial, may appear 
in the mucous membrane of the mouth, and blood may ooze from cracks 
and fissures in the lips. O. Kneise claims that in 97.5 per cent, of a 
large number of infants examined bacteria were abundant in the 
mouth at birth. Staphylococci and streptococci were particularly 
common and virulent. The bacteria evidently entered the mouth 
either before or immediately after labor. This is probably a frequent 
cause of septic oral infection. 

The Lungs. — The lungs are more or less involved in all cases. 
Bronchitis is almost invariably present, bronchopneumonia is a com- 



ACUTE SEPTIC TNFECTION OF THE NEWBORN 123 

nion complication, while pleurisy, and especially empyema, are not 
rare. The respiration is often rapid and superficial, and the respiratory 

symptoms may be the most prominent and most serious. 

The Heart. — Pericarditis is quite common, and is usually secondary 
to inflammation of the pleura or the anterior mediastinum. Endo- 
carditis is seen less frequently. 

The Kidneys. — As a rule, the urine contains albumin, casts, leuko- 
cytes, bile pigment, and perhaps hemoglobin in solution. 

The Gastrointestinal Tiaet. — The gastro-intestinal tract is usually 
involved. Vomiting and diarrhea are common, and in some cases 
the sepsis produces the typical symptoms of gastro-enteritis. The 
vomitus may be green or of a brownish tint, or may contain blood. 
The stools are frequent, thin, greenish or brownish, or may be red or 
black from blood. The abdomen may be greatly distended. Intestinal 
paralysis may occur, and if associated with abdominal tenderness 
and pain usually points to peritonitis, the probability of which is 
increased in umbilical infection. 

The Bones and Joints. — The bones and joints may show periostitis 
or osteomyelitis, the hips and shoulders being especially likely to be 
involved. If there is restricted motion, tenderness on pressure, local 
swelling, and pain on moving the joint, this diagnosis is warranted. 

Meningitis. — Meningitis of the acute purulent type may exist. 
The exudate is usually extensive, and may be associated with menin- 
geal hemorrhages or small multiple abscesses. Stupor, convulsions, 
paralysis, and bulging of the anterior fontanelle are common symp- 
toms. Lumbar puncture will confirm the diagnosis. The child is often 
dull and drowsy, and may show irregular tremors or twitchings. If 
inflammation or hemorrhages exist in the central nervous system, a 
corresponding paralysis will be observed. 

Diagnosis. — If there is local evidence of infection at the umbilicus, 
associated with irregular fever, jaundice, rapid wasting, involvement 
of the gastro-intestinal and respiratory tracts, or hemorrhages, the 
diagnosis can be made with certainty. But when the child presents no 
visible external portal of entry, and the symptoms resemble those of 
acute gastro-enteritis, pneumonia, or meningitis, it is often difficult 
to decide whether acute septic infection is present or not. The milder 
cases of gastro-enteritis running a slow course must be differentiated 
from the ordinary feeding case. Blood cultures assist in doubtful 
cases by demonstrating the presence of bacteria in the circulation. A 
negative culture, however, does not necessarily prove that the infant 
is not sufTering from septic infection, as a considerable number of 
cases of septic infection show no bacteria in the blood during 
life. 

Prognosis. — The mild cases recover; most of them, unfortunately, 
are of the severe type, and end in death. The prognosis depends upon 
the seat and severity of infection, the local or general involvement of 
the body in the septic invasion, the question whether the child was 
prematurely born or not, and its vitality. 



124 DISEASES OF THE NEWBORN 

Prophylaxis. — The newborn infant should be eared for under the 
most rigid laws of modern asepsis. The umbilicus should be treated 
as an open wound, and dressed accordingly. In hospitals and other 
institutions each infant should have its individual thermometer, basin, 
cotton, and its own mouth-wash prepared in a separate jar. The 
clothing should be changed often, and kept scrupulously clean. The 
breasts of the mother should be carefully cleansed just prior to nursing, 
and all feeding bottles should be regularly sterilized. Incubators 
for premature infants should be thoroughly disinfected after being 
occupied, and only those used that insure a constant supply of fresh 
air. A child should not be cared for by a nurse who is in attendance 
upon a septic mother. 

Treatment. — The child's nutrition should be kept at as high a 
standard as possible. Breast milk is, of course, the best nourishment, 
and the mother's nipples should be carefully cleansed before and after 
each nursing. If the child refuses to nurse, it should be fed breast- 
milk with a spoon, medicine dropper, or Breck feeder. The child 
should be kept in a room where there is fresh, moving air. Whisky 
in 15 drop doses should be given every two hours. Infusion of digitalis, 
Tfl,xx, every four hours, or camphorated oil, Til vj, given hypodermically 
three times a day, will be of service as a heart tonic. All symptoms 
of severe type should be treated as they arise. Any infectious condition 
of the mouth should receive early and careful appropriate local treat- 
ment. In all cases of septic infection the umbilicus, even if apparently 
healthy, should be washed daily with a weak antiseptic solution, 
and if there is pus in or around the umbilicus an incision should be 
made, the pus evacuated, and the abscess thoroughly washed out 
with 1 to 6 peroxide of hydrogen solution, or 1 to 2000 bichloride of 
mercury solution, and a sterile dressing applied. If an abscess forms 
at any other place, it should, if possible, be* opened, and all lesions of the 
skin or mucous membrane should be promptly and carefully treated. 
Periostitis and osteomyelitis should receive early surgical treatment. 
Cases of meningitis should be treated according to the indicatidns given 
under meningitis, the clinical diagnosis being confirmed by a lumbar 
puncture. 

DISEASES OF THE UMBILICUS. 

Disease of the umbilicus may be local or may become general by 
the spread of the infection through the umbilical veins. Normally the 
umbilical stump desiccates and drops off in about five or six days, 
although in frail and premature children this may not happen until 
several days later. 

Omphalitis. — The first symptoms are usually noticed on or after 
the sixth day. An inflammation appears at the navel, and spreads 
more or less over the surrounding abdominal wall. The folds of the 
navel become swollen and edematous, and considerable pus usually 
forms. The abdominal veins become enlarged, lymphangitis may 
develop, and also cellulitis of the abdominal wall surrounding the 



DISEASES OF THE UMBILICUS 125 

umbilicus which may end in abscess, gangrene, or infection of the 
umbilical vessels. In many instances the affection is purely local, 
and the case ends in recovery; if, however, the umbilical veins become 
infected, the condition is very dangerous. 

Treatment. — As the cause is almost invariably an infection of the 
umbilicus at or after birth, aseptic treatment of the cord at birth and 
its subsequent care are absolutely essential in every case. This includes 
asepsis as regards the mother, nurse, and physician. Many physicians 
insist that the child be kept in a separate room from its mother during 
the first two weeks; this is, of course, always advisable if she is septic. 
If an umbilical abscess forms it should be freely opened and dressed 
aseptically. The child should be well nourished with breast milk, 
and given 15 drops of whisky every two hours. 

Gangrene of the Cord. — Gangrene of the cord of the moist variety 
is not uncommon. The stump, wholly or in part, becomes moist, 
swollen, and dark, with a discharge of offensive odor. When the gan- 
grenous mass sloughs, it leaves an. unhealthy umbilical stump. Any- 
thing which tends to keep the cord moist favors the development 
of this condition. Under local aseptic treatment the disease usually 
terminates favorably. All oils, ointments, or wet umbilical dressings 
should be avoided. 

Gangrene of the Umbilicus. — This is, fortunately, rather a rare 
condition, and is seldom seen except in feeble and premature infants. 
It may develop without previous local lesion, or may follow some of the 
more common forms of umbilical infection. It usually appears between 
the seventh and twentieth days. The gangrenous area involves the 
skin, adipose tissue, and, perhaps, the underlying muscles; it may even 
perforate into the abdominal cavity, 'and involve the wall of the 
intestine. Severe umbilical hemorrhage will indicate that the gangrene 
has perforated the umbilical vessels. A few cases end in recovery, 
the gangrenous tissue sloughing off, and granulations forming at the 
edges of the necrotic area. Most of the cases terminate fatally. The 
infant rapidly becomes exhausted and profoundly toxic, and dies in 
coma, greatly emaciated. 

Treatment. — If possible, the gangrenous tissue should be removed 
with the cautery, the cauterization extending beyond the gangrenous 
area. If the condition is recognized early, this treatment offers some 
hope of cure. If, however, the child is premature, frail, or profoundly 
toxic, and the gangrene is extending, it is better to omit the use of the 
cautery, and apply hot, wet, antiseptic dressings locally. 

Umbilical Hemorrhage. — The cord may have been imperfectly 
ligated, it may have fallen off too early, or the hemorrhage may 
result from necessary or unnecessary manipulation of the umbilicus. 
In all cases of hemorrhage due to the above causes the bleeding is 
slight, transient, and devoid of danger. Unless sepsis or some local 
disease of the navel is present a profuse spontaneous umbilical hemor- 
rhage is rare, as the arterial blood-pressure falls very materially after 
birth as soon as the pulmonary circulation is established, and after 



126 DISEASES OF THE NEWBORN 

ligation of the cord the contraction of the walls of the arteries tends to 
check hemorrhage by the partial closure of the lumen. of the vessels. 
In fact, the normal fall in the blood-pressure and the contractility of 
the arterial coats would, in the large majority of newborn infants, 
prevent a fatal umbilical hemorrhage, although in asphyxia, atelectasis, 
prematurity of birth, and congenital heart disease, a higher blood- 
pressure exists. Bleeding may take place from the umbilical arteries 
as they emerge from the body, but this is an uncommon form of 
umbilical hemorrhage, which is seen only after detachment of the cord ; 
it occurs from the fourth to the fifteenth day. 

In the large majority of cases of umbilical hemorrhage the bleeding 
takes place from the surface of the umbilicus, the blood simply oozing 
out from the small vessels in and around the navel; it may occur before 
or after the cord has fallen. The amount of blood lost is usually large, 
and the hemorrhage may be more or less continuous for days, often 
ending fatally; the mortality is over 75 per cent. 

The cause in most cases is a septic infection, and umbilical 
hemorrhage is simply one of the varieties of hemorrhage associated 
with this condition. Sometimes hereditary syphilis causes the hemor- 
rhage, and a careful inquiry should be made into the family history, 
especially as it is a well-recognized fact that syphilis causes definite 
changes in the bloodvessels. Umbilical hemorrhage as a symptom of 
hemophilia is extremely rare. 

Treatment. — Bleeding from the cord may be controlled by a broad, 
firm ligature. Slight bleeding from the umbilicus may be checked 
by compresses moistened in adrenalin solution, 1 to 1000, or by a 
suture of the umbilicus. In some cases gelatin in four dram doses, 
carefully sterilized and injected under the skin, and repeated in eight 
hours if necessary, has been used with more or less success. The general 
treatment of septic infection should be carried out as indicated under 
that heading. 

HEMORRHAGE IN THE NEWBORN. 

Hemorrhagic Disease of the Newborn. — In the newborn hemorrhage 
is usually a symptom of infection. It may be hetero-infection or auto- 
infection, although the former is much more common than the latter. 
While sepsis is accepted as being the most common cause of hemor- 
rhage, some cases are undoubtedly due to syphilis. In both sepsis 
and syphilis hemorrhage is usually but one of a number of symptoms, 
and the bleeding is generally not profuse. The more closely, however, 
these cases of hemorrhage are studied, the more evident it becomes 
that sepsis is, as a rule, the underlying cause. This applies also to 
those cases where hemorrhage may be the main, or is, in fact, the only 
symptom. To some extent at least, the bleeding usually depends upon 
some abnormal conditions present in the substances associated with 
blood coagulation. Under this heading spontaneous hemorrhages 
alone are considered. A few only of the hemorrhages that occur in 
the first few days of life are due to hemophilia. 



HEMORRHAGE IN THE SEW BO Its 127 

Hemophilia is very much more common in boys than in girls, the 
proportion being as thirteen to one, whereas hemorrhage in the new- 
born is about as common in the female as in the male, and the study 
of a large number of histories of hemophiliacs does not show that they 
were subject to hemorrhage in the first few days of life. The bleeding 
rarely continues longer than a few days or weeks, and the strong and 
healthy child is as liable to hemorrhage as the delicate or premature. 
The disease resembles an acute infectious process in that it runs a 
self-limited course and ends in either death or complete recovery. 
The hemorrhages are especially apt to occur from mucous membranes, 
as the mouth, umbilicus, or gastro-intestinal tract; less commonly 
in the meninges of the brain, abdominal cavity, pleura?, lungs, thymus 
gland, and suprarenals; it may also be subcutaneous. While it is 
usually spontaneous, it may also follow a slight bruise, or may occur 
over areas of pressure, as the occiput, the back, and the sacrum. More 
cases occur in maternity hospitals than in private practice. The disease 
ordinarily runs its course in from one to four days, occasionally in 
seven to nine. The hemorrhage usually appears between the second 
and seventh days, rarely after the fifteenth day, and is often the first 
sign of the disease. The amount of blood lost is usually not great, 
but a slow oozing persists, and from the onset of the bleeding the infant 
is markedly prostrated. A moderate fever is quite common, although 
the temperature may be normal or subnormal. At autopsy no definite 
pathological changes are found to account for the hemorrhage, but 
gastric and duodenal ulcers have been noted in a few cases. Blood 
cultures have, as yet, thrown no light upon the etiology. That the 
disease is due to different forms of infection is, however, the general 
belief, although in the first week or two of life the marked changes 
occurring in the blood, the weakness of the walls of the bloodvessels, 
and the change from intra- to extra-uterine circulation are factors 
that certainly predispose the infant to hemorrhage. If the bleeding 
is from the nose alone, hereditary syphilis should be suspected. 

The prognosis is poor, the mortality being about 75 per cent. 

Treatment. — To accomplish anything treatment should be prompt. 
In hemorrhage from the stomach or bowel a 5 or 10 per cent, solution 
of gelatin may be given in large amounts by the mouth. Only well- 
sterilized gelatin should be used; the English gelatin is the safest, 
as the commercial product often contains the tetanus bacillus. It may 
also be used subcutaneously, 4 drams (15 c.c.) of a 10 per cent, solu- 
tion being the usual dose. Adrenalin, 1 to 1000 solution, is valuable 
if applied locally on gauze, and for gastro-intestinal hemorrhage adre- 
nalin by the mouth in 2-grain doses may be given every three hours. 

Transfusion of blood is a valuable remedy, and should, when pos- 
sible, be resorted to in all severe cases. In the hands of the experi- 
enced surgeon it is not as difficult an operation as many would lead us 
to suppose, and recent improvement in technic has made it more 
easy of accomplishment. Xext to transfusion, injections of sterile 
normal human blood serum offer the greatest hope of saving the infant's 
life. The blood should be withdrawn and kept under absolutely 



128 DISEASES OF THE NEWBORN 

aseptic conditions; 5| drams (20 c.c.) of the serum should be injected 
subcutaneously every six to eight hours as long as the hemorrhage 
persists. Improvement in the child's general condition is usually 
noted -immediately after the transfusion or serum administration, 
and the bleeding is often checked in twenty-four to forty-eight hours. 

Normal horse serum may be used if transfusion of human blood 
serum is impracticable. It should be injected subcutaneously in doses 
of 2 J drams (10 c.c), and repeated every eight to twelve hours if no 
improvement is apparent. If the infant has suffered from a profuse 
hemorrhage, transfusion of blood or saline solution is the best treat- 
ment. Whole blood injections are simple and easy of accomplishment. 
Four drams (15 c.c.) of blood are withdrawn by a syringe from a vein 
in the donor's forearm, and immediately injected subcutaneously into 
the infant; later, blood serum or transfusion can be employed, or the 
whole blood injections can be repeated every eight to twelve hours. 
Diphtheria antitoxin, owing to its being so readily obtained, may be 
used instead of human or horse serum. Lactate of calcium, in 5-grain 
doses every four hours, is of benefit in some cases, while breast-milk 
and also whisky, 20 drops every two hours, tend to increase the 
child's resistance. 

Acute Fatty Degeneration of the Newborn (Buhl's Disease). — The 
symptoms in this condition are associated with fatty changes in the 
liver, kidneys, and heart, and hemorrhages are often found in these 
organs at autopsy. The liver and spleen are enlarged, and jaundice 
is a common symptom. The child is born asphyxiated, and is with 
difficulty made to breathe. Hemorrhages occur from the umbilicus, 
the blood oozing from the surface of the navel. There are also hemor- 
rhages from the stomach, bowel, and, in some cases, from the mouth, 
conjunctiva, and nose. Profuse hemorrhages beneath the skin are 
common, and there may be considerable edema. The temperature is 
normal. The disease is rare, causes profound depression, runs a rapid 
course, and usually terminates fatally in a week or two. It is undoubt- 
edly due to septic infection, the portal of entry in the majority of 
cases probably being through the umbilicus. 

Epidemic Hemoglobinuria (WinckePs Disease). — This affection 
occurs in the first few days of life, its special symptoms being cyanosis, 
jaundice, and hemoglobinuria. 

Etiology. — It is undoubtedly due to infection, and the cases reported 
by Winckel occurred as an epidemic in an institution; the infection 
was probably conveyed through bathing or drinking water. At 
autopsy the colon bacillus and streptococcus have been found in the 
blood and internal organs in a few cases. 

Pathological Anatomy. — While all the evidence points to septic 
infection of the newborn, still the umbilicus and the umbilical vessels 
are normal. The spleen is swollen and contains much blood pigment. 
The kidneys are enlarged, the tubules filled with hemoglobin crystals. 
Minute hemorrhages are seen in almost all of the organs, while larger 
amounts of blood may be found in the stomach, bowel, liver, and pleura. 



HEMORRHAGE IN THE NEWBORN 129 

The mesenteric glands and Fever's patches are swollen, and there is 
fatty degeneration of the liver and other internal organs. 

Symptoms.— At birth the infant is apparently healthy and normally 
developed. Usually about the fourth day it is noticed that the baby 
is extremely fretful and more or less cyanotic; the symptoms rapidly 
progress, the child becoming profoundly prostrated, with rapid pulse 
and respiration. Jaundice of a severe type appears, the skin becoming 
deep yellow or bronze, the cyanosis more marked, especially on the 
body and legs, while the temperature may be either normal or slightly 
elevated. The infant loses strength rapidly. Diarrhea or vomiting 
may develop, urination is frequent, and the urine voided very dark, 
containing blood cells, hemoglobin, renal epithelium, granular casts, 
and a small amount of albumin. Before death the child often becomes 
comatose, and may die in convulsions. The typical urinary findings 
will confirm the diagnosis. The disease is fatal in the severe form, 
and, as it is undoubtedly the result of an infection, the treatment is 
the same as that recommended for septic infection. 

Melena Neonatorum.— The name, melena, is applied to those cases 
in which bleeding occurs either from the bowel, the stomach, or from 
both. It is, of course, well understood that hemorrhage from the 
stomach or bowel may occur in various diseases, and may be a symp- 
tom of many different pathological conditions; but, as hemorrhage is 
often the only dangerous symptom that presents itself, and one which, 
if not controlled, may cause the death of the infant, its consideration 
is important. Melena is not the name of a definite specific disease, 
but, as the term is generally used, it describes a symptom-complex; 
therefore, it is well, perhaps, to retain it. The more, however, one 
studies the conditions associated with hemorrhage of the newborn, 
the more thoroughly one is convinced that it is due to sepsis. The study 
of the coagulation of the blood in these hemorrhagic cases assists 
somewhat in explaining the persistence, at least, of the bleeding. The 
elements that are normally present in the blood and which produce 
coagulation may not be present in normal amounts or there may be a 
normal amount of some of these elements and a deficiency in others. 
Whipple has recently demonstrated the interesting fact that old fibrin 
has been found in the alveoli of the lungs, but that no fibrin of fresh 
formation exists, which proves that the elements necessary for coagula- 
tion were present at birth and that they disappeared in the first few 
days following birth. The reason why transfusion of blood and sub- 
cutaneous injections of blood are beneficial in these cases is quite clear 
when we consider that transfused blood or injected serum may supply 
the elements needed to restore coagulation. 

Melena includes only those cases in which the source of the bleed- 
ing is in the gastro-intestinal tract. Blood from the nose, lips, or 
mouth may be swallowed by the infant and later vomited. A bleeding 
fissure in the mother's nipple may result in the infant's swallowing 
blood during nursing, and this may subsequently be vomited or appear 
as blood in the stools; this condition is not spoken of as melena. 
9 



130 DISEASES OF THE NEWBORN 

Hemophilia is rarely the cause of hemorrhage during the first few days 
of life ; as proof of this is the fact that the cases of melena that recover 
show no tendency to subsequent bleeding. 

In the newborn gastro-intestinal hemorrhages may occur in many 
conditions, as already stated in the consideration of sepsis, the hemor- 
rhagic diseases of the newborn, Buhl's disease, and Winckel's disease. 
But all of these affections give rise to other decided symptoms besides 
the hemorrhages; therefore, they can be differentiated, at least clinic- 
ally, from melena. 

Etiology. — Sepsis is the most common cause of hemorrhage in the 
newborn, and, while the hemorrhage of sepsis is not usually a single 
hemorrhage unconnected with other symptoms, still this undoubtedly 
does occur, and sepsis is now accepted as the usual cause of melena. 
Many observers regard syphilis as a cause, since in this disease 
the intima of the small vessels and capillaries becomes thickened, cell 
infiltration and subsequent connective-tissue formation produce a 
narrowing of the lumen and cause venous stasis and hemorrhage. In 
the newborn, syphilis of the liver, as well as abdominal growths and 
congenital heart disease, may also produce hemorrhage from the 
stomach or bowel. In a few cases a gastric or duodenal ulcer has been 
found at autopsy, and less often an ulcer in the esophagus. A thrombus 
of the umbilical vein or of the ductus arteriosus Botalli may possibly 
explain the presence of the ulcers; this results in emboli of the pan- 
creatic, duodenal, or gastric artery, followed by necrosis and ulcer. 

Some cases of melena are caused by abdominal pressure and injury 
during labor; and, as gastro-intestinal hemorrhage may be associated 
with cerebral hemorrhage, a bulging fontanelle, slow pulse, and 
asphyxia, associated with gastro-intestinal hemorrhage, would indicate 
a possible connection between the brain and the melena. If melena 
is noticed within two or three hours after birth it suggests a birth 
injury, and it is probably due to some other cause than sepsis, especially 
if there are no other evidences of sepsis before or during labor. In 
many cases of melena, however, the child is at birth apparently 
normal and in perfect health. In melena the bleeding usually begins 
in the first four days of life, often on the first or second day. In some 
cases no definite pathological condition can be found; in others a 
simple congestion without ulceration or small hemorrhagic areas with 
erosions of the gastro-intestinal mucous membrane are seen at autopsy. 
Blood cultures or a Wassermann may assist in deciding as to the 
septic or syphilitic origin of the melena. 

Prognosis. — This depends upon the cause of the melena, and upon 
the amount of blood lost. In some cases the hemorrhage is small, the 
bleeding does not recur, and the child is not seriously ill. In others 
the hemorrhage is more profuse, and the child becomes pallid, pros- 
trated, and is in shock. In the most severe cases the infant passes 
rapidly into collapse and dies. The mildest symptoms may be followed 
by the most alarming hemorrhage, so that one is always fearful of the 
outcome until the child has entirely recovered. 



HEMORRHAGE IN THE NEWBORN 131 

Treatment. — The best treatment is transfusion of blood repeated 
in twenty-four hours if necessary; next to transfusion is the injection 
subcutaneously of human blood serum, 4 drams (15 c.c), which may be 
repeated every eight or twelve hours as long as the symptoms persist. 
Horse serum may be used if it can be procured more readily than 
human serum, or diphtheria antitoxin, containing, as it does, horse 
serum, may be employed. The two latter may be used in doses of 3 
drams (11 c.c), and repeated every eight or twelve hours if necessary. 
Sterile gelatin in 10 per cent, solution, injected subcutaneously in 
4 dram (15 c.c.) doses and repeated every twelve hours, is of value in 
this disease and it may also be given by the mouth in 5 per cent, 
solution every three hours in as large amounts as the child can take 
and retain without producing nausea and vomiting. If the child is 
extremely weak, with cold extremities, whisky, 20 drops every two 
hours, should be given, and external heat applied. 

Erysipelas. — Erysipelas is due to the entrance into the system of 
septic material. The infection usually takes place through the umbili- 
cus, although it may enter through a scratch or abrasion in any 
portion of the body, especially in the genital region, seal]), or face. 
While erysipelas in the newborn was formerly not uncommon, the 
modern practice of aseptic obstetrics has reduced the number of cases 
very greatly. 

Etiology. — It is not as yet definitely settled what the specific organism 
of erysipelas is. Many observers believe that streptococci positively 
produce the disease, and there is considerable experimental proof to 
support this view. The infection may be brought to the child by the 
nurse, the physician, unclean dressings or soiled clothing. Erysipelas 
is more liable to develop in the infant if the mother is septic, the 
infection being conveyed to the child by the infected lochia either 
through infected dressings, clothing, or the soiled hands of an 
attendant. 

Symptoms. — The infant offers only a slight resistance to the infection, 
consequently the disease shows a tendency to spread and frequently 
extends more or less rapidly over a wide superficial area. In early 
life it may also involve not only the skin but also the subcutaneous 
tissues. It usually- appears first from the sixth to the tenth day after 
birth, and, if at the umbilicus, the redness and swelling quickly involve 
the neighboring portions of the abdomen and spread to the pubic 
region and down one or, perhaps, both thighs. If it begins at the 
corner of the eye or in the region of the ear, or in the scalp, it quickly 
spreads over the entire face, and commonly extends also to the neck 
and upper chest. The involved area is red, edematous and hot. The 
systemic symptoms are marked. There is usually high fever, 102° 
to 105° F., although the temperature often shows wide fluctuations, 
and it may be normal or subnormal. Rapid pulse, marked prostration, 
and often loss of appetite, with vomiting and diarrhea and, possibly, 
convulsions are common symptoms. Wasting may be rapid, although 
if the child takes and retains the breast, and there is no diarrhea, it 



132 DISEASES OF THE NEWBORN 

may not be especially noticeable. Hemorrhages from the navel, 
intestine or beneath the skin may occur, and jaundice may be a 
marked symptom. Bronchopneumonia is, in erysipelas, as in so many 
of the dangerous illnesses of infants, a not unusual complication. 
Septic arteritis, phlebitis, and peritonitis are quite often associated 
with an erysipelas which originates at the umbilicus, and sloughing 
of the subcutaneous tissues is much more common in infants than in 
older children or adults. Septic infection of the lungs, cerebral men- 
inges, and pericardium are frequently found at autopsy. The liver, 
kidneys, and spleen are less often involved. 

Prognosis. — Erysipelas in the newborn, especially if it begins at 
the umbilicus, is a dangerous disease and often ends fatally, and if 
internal organs are involved the prognosis is unfavorable. The less 
severe cases which involve the scalp, face, and chest are dangerous but 
not necessarily fatal. In children of one year or older the prognosis 
is much more favorable, although even in the older children, in my 
experience, the disease shows a much greater tendency to spread than 
in the adult and is apt to run a much longer course. 

Treatment. — As erysipelas in the newborn is the result of septic 
infection prophylactic treatment should embrace the aseptic care 
of all lesions of the skin or mucous membrane occurring at birth. 
The umbilicus especially should be treated according to modern 
aseptic methods. Dry dressings are the only ones that should be used. 
At the first sign of infection, strict antiseptic methods are necessary. 
Daily washing of the infected part with 1 to 1000 bichloride solution 
and the application of gauze kept wet with this solution are of assistance 
in limiting the spread of the infection. Prophylaxis also includes 
the absolute separation of the child from a septic mother. It is of the 
first importance to sustain the child's strength and for this purpose 
breast milk is by far the most useful food. Whisky, 10 drops every 
two hours, may be given to combat the general depression. 

Local applications to the affected area tend to relieve somewhat the 
intense burning and pain. Ichthyol, 10 to 15 per cent, in lanolin, 
is one of the best local applications. It partially relieves the pain 
and may possibly have some influence upon the erysipelatous inflam- 
mation. Gauze dressing kept wet with normal salt solution and applied 
over the inflamed portion lessens the intense burning of the skin. 
Unguentum Crede rubbed into the healthy skin daily is recommended 
by many careful observers. Antistreptococcic serum, 4 drams (15 c.c), 
administered every twenty-four hours, is a remedy that has been largely 
used in the treatment of this condition, and, while the results are not 
always favorable, still there is no question but that it is well worthy 
of a trial in severe cases. Vaccine treatment vies with antistrepto- 
coccic serum as the best method to employ. Unfortunately erysipelas 
of the newborn is usually of such a virulent type that often no plan 
of treatment can bring about a cure, but, personally, I believe that all 
cases should have the benefit of either the vaccine or antistreptococcic 
serum. One must not expect the rapid cures that have so often been 



TETANf 78 133 

reported as following this treatment in adults, but if used daily it is 
of assistance in the erysipelas of the newborn although of much 

greater benefit in erysipelas of older ehildren. 

TETANUS (TRISMUS NEONATORUM). 

This is an acute infectious disease due to the entrance into the 
body, through a wound, of the tetanus bacillus. 

Etiology. — The infection usually occurs through the umbilical 
wound, although it may enter through the umbilical vessels or any 
wound or abrasion in the child's body. It is essentially a filth-born 
disease and is usually found where the surroundings of the child are 
unclean. It may be carried to the open umbilical wound by soiled 
hands and dressings, or by the dust-laden air. The bacillus is usually 
found in the top-soil of garden earth, but not at a greater depth 
than one foot, and in the excrement of animals, especially that of the 
horse. Tetanus is more common in tropical countries, and the colored 
race is particularly susceptible. Since the cause of the disease has 
become known the number of cases has greatly diminished. 

The bacilli of tetanus increase rapidly in numbers at the point of 
infection, but remain for a short period of time only, being evidently 
short-lived. A few only of the bacilli are absorbed ; the toxins produced, 
how r ever, enter the lymph channels and combine with the motor 
cells, in the anterior cornua of the cord and medulla, increasing greatly 
the excitability and irritability of these motor cells, so that the slightest 
external irritation is sufficient to produce tetanic spasms. There is no 
involvement of the muscles of the peripheral nerves, as is shown by the 
fact that the tetanic spasms cease if the nerve trunks are divided. 
So far as is known the disease produces no definite lesions in the 
internal organs of the body. 

Symptoms. — The first symptoms usually appear from the fifth to the 
twelfth day after birth; rarely after three weeks. The special symp- 
toms are — continued contraction of the voluntary muscles, and the 
development at irregular intervals of tetanic spasms of greater or 
less severity. The first symptom noticed is the inability of the child to 
nurse; this is due to the fact that the child cannot open its mouth 
— it already has trismus or lockjaw. The spasm spreads to the face 
producing a characteristic expression — the so-called risus sardonicus. 
The forehead is drawn into deep wrinkles, the eyes are tightly shut, the 
mouth is closed and puckered. The muscles of the neck and back are 
the next involved. The head is drawn backward, the abdominal 
muscles become fixed, the arms are flexed at the elbows, the legs are 
stiff and extended. The elbows and knees can, with difficulty, be 
either flexed or extended, and opisthotonos develops. The tonic 
spasms increase in number and severity and the slightest reflex is 
sufficient to produce the spasm. The merest touch, the effort of 
nursing, or a current of air may bring on an attack. As the disease 
progresses the periods of relaxation occur less often and are of shorter 



134 DISEASES OF THE NEWBORN 

duration. The arms remain more or less continuously stiff and flexed, 
the hands tightly closed, the legs stiff, the jaws closely locked, and the 
child swallows with difficulty or not at all. Owing to a spasm of the 
laryngeal muscle the respiration may be noisy and dyspnea and 
asphyxia may be more or less marked. The contraction of the muscles 
and the spasm may relax during sleep. The pulse is accelerated, 
albumin is usually present in the urine, and there may be other signs 
of septic infection. The navel may appear normal, although very 
commonly it presents an unhealthy and ulcerated appearance, accom- 
panied by a thick, purulent discharge. In the severe cases the tempera- 
ture is usually high, 104° to 106° F. The fatal cases usually run a rapid 
course, death occurring commonly in from six to forty-eight hours 
after the onset of the symptoms. Recovery may occur, however, even 
in the w r orst cases. In the milder cases the temperature is lower, 
100° to 102° F., and the spasm is limited to the jaws, face, and neck. 
The attacks gradually diminish in frequency and severity, and the case 
may go on to recovery. In these cases the spasm relaxes to a greater or 
less degree, the child gradually breathes and swallows better, and the 
intervals between the spasms increase in length. In those infants that 
recover the symptoms last, as a rule, from a few 7 days to three weeks. 
The child is left emaciated by the disease, and following the spasm is 
invariably weak and exhausted. 

Diagnosis. — The diagnosis is usually made without any great diffi- 
culty. The development of trismus as an early sign, and the continued 
contractions, well marked in the severe cases and present in a less 
degree in the mild cases, with the occurrence of tetanic spasms at 
irregular intervals, are very suggestive of the disease. Tonic con- 
vulsions may occur with meningitis, and congenital spastic paraplegia 
may follow cerebral disease, but lockjaw is not present and slight 
external causes do not provoke a tetanic spasm. 

Prognosis. — This depends upon the severity of the case, the time 
at which the first symptoms develop, and the duration of the symptoms. 
The more severe the symptoms and the earlier they appear the graver 
the prognosis; the later the symptoms develop and the longer they 
persist the better the prognosis. Sporadic tetanus is less apt to be 
fatal than epidemic tetanus. Modern treatment is helpful in reducing 
the mortality; although probably 75 per cent, of the cases end fatally. 

Treatment. — As the majority of cases occur from umbilical infection 
the aseptic care of the cord is of the utmost importance. This includes 
the aseptic care of the umbilicus until the w r ound at the navel has 
entirely healed. In those regions wdiere epidemics of tetanus have 
occured the antiseptic treatment of the cord and its subsequent care 
are essential as a means of prophylaxis. As soon as the first suspicious 
symptoms of tetanus appear, tetanus antitoxin should be administered. 
In order to be of much benefit the antitoxin should be used early, as 
the toxins of tetanus combine with the motor cells in the cord and 
medulla, and after combination are only slightly influenced by the 
antitoxin administered. The toxins still circulating in the blood can, 






SCLEREMA 135 

however, be neutralized. The antitoxin apparently does no harm 
even if administered in Large doses, and consequently should be used 
freely. It may be administered by lumbar puncture, intravenously 

or subeutaneously. Ten cubic centimeters of spinal fluid should be 
withdrawn by lumbar puncture, and 10 c.c. of tetanus antitoxin 
injected every twelve or twenty-four hours as long as the severe 
symptoms persist; if the symptoms become less marked the injections 
may be given every second or third day. If not injected into the 
spinal canal the antitoxin may be given either intravenously or sub- 
eutaneously in the same doses as recommended by lumbar puncture. 
Bromide of soda in 5-grain doses combined with chloral, 1 grain, 
may also be given every hour either by the mouth or rectum as long as 
the violent symptoms persist. Small doses are useless and large ones 
essential in assisting to control the symptoms. If, owing to the trismus, 
the child is unable to swallow it may be \'vd breast milk with a tube 
passed through the nose. Absolute rest and quiet should be insisted 
upon, and, as the tetanic spasms are often produced by very slight 
causes, all external sources of irritation should be removed. While 
the treatment of tetanus with antitoxin has not given good results, 
still, in such a dangerous disease, it is well worthy of trial, and, if 
possible, should be administered in every case. 

SCLEREMA. 

In this disease the skin and subcutaneous tissues become firm and 
hard. The induration of the tissues usually appears first in the legs 
below the knees and gradually extends upward, involving a portion or 
practically all of the body. The genitals, soles of the feet, and palms 
of the hands are not involved. 

Etiology. — The etiology is still in doubt. The composition of the 
fat of the newborn, containing as it does about 20 per cent, less of 
oleic acid as compared with the adult, and a greater amount of stearic 
and palmitic acids, is believed by some to predispose the infant to 
the disease. Others believe that it is an infectious disease, and, while 
its infectious origin has not been proven, personally I believe that it 
will be shown to belong to this class. Streptococci have been found at 
autopsy. Still others believe it is associated with certain changes in 
the nervous system. Prematurity and unhygienic surroundings are 
predisposing causes, and it is more common in institutions than in 
private practice. In atrophic infants a few months old, sclerema may 
follow cholera infantum or an enteritis with frequent watery stools. 

Pathological Anatomy. — The skin and subcutaneous tissues are dry 
and hard. The superficial fat is firm and dry. Atelectasis is often 
present, and enteritis is not uncommon in children who have lived for 
some days. Hemorrhages into the lung and myocardium may occur. 

Symptoms. — It is an uncommon disease, and may occur in the first 
few days of life, or, in weak and premature infants, as late as the 
third or fourth month. The most common locations are the calves of 



136 DISEASES OF THE NEWBORN 

the legs, mons veneris, cheeks, thighs, and lower portion of the trunk, 
more particularly those parts of the body where fat is abundant. 
As a rule the disease lasts in the severe cases only a few days. The 
temperature falls soon after birth and never returns to normal. A 
temperature of 95° F. is quite common; it may fall as low as 85° F., 
and cases have been reported where it has fallen as low as 72° F. The 
baby feels cold, and its skin is hard and atrophied. The child loses in 
weight, its legs become stiff, and it lies absolutely quiet in bed. 
The mucous membranes are dry, the sleep is restless, the urine is 
scanty, and there is constipation. The amount of nourishment taken 
is small, the respirations are superficial and slow, often below 18. 
The pulse is slow, falling to 60 or even lower in some cases, and is 
difficult to find. The lips and finger tips may be cyanotic, and there 
may be more or less associated edema. The skin may be of a blue or 
reddish tint, and a serous fluid exudes if the skin is slightly incised 
or punctured. The child utters a sharp cry; this is more often noticed 
in older children. Jaundice may be present, albumin in the urine is 
not uncommon, and, less often, granular casts and red blood cells are 
found, and occasionally, sugar. The younger the child the more serious 
the prognosis and the more rapid the course of the disease. In the 
fatal cases the asthenia becomes progressively greater, and the infant 
sinks into coma and dies. In the cases that recover the hardness of 
the skin and subcutaneous tissues gradually lessens, the normal color 
returns, and the infant slowly gains in vitality and strength. Effusions 
have been found in the pleura and peritoneum, and pneumonia may 
develop as a complication. 

Diagnosis. — Hardness of the skin, subnormal temperature, and stiff- 
ness of the body are characteristic. 

Prognosis. — The prognosis is bad in the newborn; probably about 
35 per cent. die. The more vigorous the child the better is the prospect 
of recovery. 

Treatment. — The best results are obtained by combating the low 
bodily temperature. This is best accomplished by placing the child 
in an incubator, or by keeping it surrounded with hot water bags, or 
the heat may be supplied by an electric warmer. Hypodermoclysis 
of normal salt solution, or the introduction of salt solution per rectum 
according to the Murphy method, is a treatment that has apparently 
been beneficial in some cases. The child should be nourished by 
breast milk. If too weak to nurse the breast milk may be fed to the 
infant in small quantities at regular intervals. 

SCLERO-EDEMA. 

This is not a rare disease. It is most common in small, weak, and 
premature infants or in twins. A history of syphilis may exist. It 
has been found associated with congenital heart disease and with 
nephritis. It is most likely to appear in winter and in cold climates, 
in institutions and hospitals, and where the surroundings, and hygienic 






SCLERO-EDEMA 137 

conditions are unfavorable. It usually develops between the second 
and fifth (Jays of life, rarely after the fifteenth day. 

Etiology. — Poor circulation and feeble respiration are factors present 
in practically all cases. If an infant so affected is exposed to cold it 
increases the liability to develop this condition. It is claimed by some 
that sclero-edema is the result of an infection. 

Pathological Anatomy. — An exudate is present in the skin and 
underlying fatty and muscular tissues. Venous congestion is found in 
the organs of the abdomen particularly, congestion of the pul- 
monary tissues with minute hemorrhages is common, and the myo- 
cardium may show fatty changes. The microscopic examination 
of the skin shows no specific lesion; only a swelling and dilatation of 
the lymphatics and minute vessels can be demonstrated. 

Symptoms. — It is noticed almost immediately after birth that the 
infant is restless and nurses poorly. The edema usually appears 
first on the dorsum of the foot, and in many cases is soon afterward 
seen in the cheeks and inferior portion of the abdomen. The affected 
tissues are swollen and hard and pit on pressure. The skin and sub- 
cutaneous tissues are much more tense than is usually found in edema, 
and the muscles are also more or less involved, although to a less 
degree. The affected part may be a reddish pink, blue, or mottled 
color, and the superficial tissues may be lifted up from the underlying 
structures. The skin feels cold, and if the swelling is extreme the 
child's body is stiff and almost motionless. The infant, owing to 
edema, does not lose weight. The temperature is subnormal in all 
cases. In mild cases it may average 95° F., and in severe ones it may 
fall to 90° F., or even 85° F. The pulse is weak and the respiration 
unnaturally. slow. The urine is diminished in amount but albumin 
is not usually present. Swelling of the scrotum and penis generally 
occurs and a large part of the body may be involved. In the worst 
cases the child gradually becomes weaker and passes into a stupor 
which ends in death in from three to six days. In the milder cases the 
temperature gradually returns to normal, the child's respiration and 
circulation improve, the edema slowly disappears, and the patient 
recovers, the duration of the disease being eight to fourteen days. 
Pneumonia may appear as a complication. 

Diagnosis. — In well-marked cases the diagnosis is not difficult. 
In sclerema the affected parts do not pit on pressure, they are much 
firmer than in sclero-edema, and the scrotum and penis are not 
involved. In the edema of nephritis the tissues are much softer and 
more pliable. 

Prognosis. — In the mild cases the prognosis is favorable but is bad 
in severe cases, especially if heart disease, pneumonia, or nephritis 
coexist. 

Treatment. — Prophylaxis includes the prevention of unnecessary 
chilling of the body in weak and premature infants, the application of 
external heat in all such cases, and insistence upon breast-feeding. 
The most important part of the treatment is the application of external 



138 DISEASES OF THE NEWBORN 

heat. This is best accomplished by placing the child in an incubator, 
or it may be surrounded with hot water bags, and its entire body 
wrapped in cotton kept in place with woolen bandages. Hot baths 
are also of assistance and a thorough massaging of the child with 10 
per cent, of iodide of ammonium in glycerine has been recommended as 
having served a useful purpose. Oxygen inhalations are of benefit, 
and breast feeding is absolutely essential. If unable to nurse, the 
infant must be fed with a spoon; medicine dropper, or by gavage. 

ACHONDROPLASIA (CHONDRODYSTROPHY— MICROLELIA) . 

In this disease the arms and legs at birth are short in proportion 
to the trunk, which is of about the normal size. If the children affected 
survive the first few years of life, they often live on to advanced age, 
and become robust and muscular, but are dwarfs. 

Etiology. — The disease affects both sexes equally, but is usually 
transmitted by males, and has been known to exist in three successive 
generations of males. The children of parents who have achondroplasia 
may inherit the disease or may be absolutely normal. The changes 
in the affected bones probably occur in the first few months of fetal life. 
There are no known predisposing influences, the true cause being 
entirely a matter of conjecture and theory. 

It has been suggested that a perversion of the internal secretion 
which affects the development of the epiphyseal cartilages may be the 
cause; that the changes may, possibly, be toxic in nature; may be 
due to an infection; or may be associated with certain changes in the 
placenta. Summers and Wallace have recently described a cretinistic 
variety of achondroplasia in which certain changes were found in the 
thyroid gland ; but in these cases there were cretinistic symptoms that 
are not present in typical cases of achondroplasia. 

Pathological Anatomy. — In this disease the bony system of the infant 
at birth shows deformities which are the result of interference with the 
normal deposit of bone cells in the fetal cartilage. No changes, or but 
slight ones, are found in those bones in which ossification develops 
intramembranously — as in the flat bones of the skull — nor in those 
which have a tendency to remain cartilaginous in utero; but changes 
are especially noticeable in those bones in which ossification of the 
cartilage normally takes place in fetal life. 

The bones of the arms and legs are the ones most markedly deformed. 
The tribasilar bone in the floor of the skull often partly ossifies during 
fetal life, and prevents normal development of the base of the skull, 
consequently the cranium is expanded above and an unusual promi- 
nence of the parietal and frontal bones results. The faulty nutrition 
of bone cells is especially marked in the long bones — bowing and 
shortening them — and is the result of interference with endochondral 
ossification which is most marked at the extremities of the long bones. 

The pathological changes are found only in endochondral ossifica- 
tion. Bone formation from the periosteum continues, and the shafts 






ACHONDROPLASIA 



139 



of the long bones are formed largely from this periosteal growth. The 
epiphyses arc more or less enlarged. The long hones fail to increase in 

length owing to dystrophy of the epiphyseal cartilages during intra- 
uterine life; in some eases a fibrous ingrowth of the periosteum between 
the epiphysis and the diaphysis is present and tends to cheek the 
increase in length. 

The thyroid gland and all other organs are apparently normal. 
The chest is smaller than normal, and the ribs are badly formed. The 
bones of the limbs, the ossa innominata, the ribs, and the basa occipital 
are especially affected. 




Fig. 20. — Achondroplasia in a child aged two years. 



Symptoms. — The infant may be stillborn or die in the first few 
weeks of life. The short arms and legs, with the trunk much longer in 
proportion than the extremities, produce an unusual tvpe of dwarf, 
the ordinary height being from 40 to 48 inches. The upper arms and 
the thighs are proportionately shorter than the forearms and legs. The 
head is large, with prominent forehead and saddle-shaped nose, which 
constitute a characteristic type of face. The features are large and 
massive. 

The maximum circumference of the head is above the normal, 
and may suggest hydrocephalus, although hydrocephalus and chondro- 
dystrophy have nothing in common. The normal spinal curve in the 
lumbar region is much exaggerated, the scapula? are short. The 
abdomen is large and prominent, the buttocks unnaturally thick and 
heavy, the genital organs are normal. 



140 DISEASES OF THE NEWBORN 

During- early child life the muscular development is usually poor, 
and the child is late in walking. The anterior fontanelle often remains 
open until the end of the second or third year, or even later. As the 
child grows older, the muscles of the arms, legs, and body often become 
unusually well developed, and the resemblance to cretinism is more or 
less marked. The condition is, however, not of the same nature as 
cretinism, and is entirely uninfluenced by thyroid treatment. - The 
hands are thick, the fingers short and nearly of equal length, and the 
fingers are spread apart by an usual development at the second joint, 
which produces the so-called "trident hand." 

Mentally the children affected are usually rather subnormal, but 
their mental powers are not markedly defective, and they may even 
be normal. As a rule, however, they develop slowly, are late in talking, 
and behind the normal child in acquiring knowledge. The deformity 
in the sacral region and pelvis caused by defective ossification of the 
innominate bones may make normal labor difficult and necessitate the 
use of forceps, or, possibly, the performance of Cesarean section. 

Diagnosis. — The condition has been confounded with hydrocephalus, 
rickets, and cretinism; but careful examination will invariably result 
in a correct diagnosis. X-ray plates will show the short and curved 
bones of the arms and legs, and will aid in the recognition of the disease. 

Prognosis. — The general nutrition of the infant is affected, as is 
evident from the poor ligamentous and muscular development. Many 
of the children die during birth, or, owing to poor development, soon 
afterward; others, as has been stated, may live to extreme old age. 
They marry and have children, and their offspring may either show 
achondroplasia or be absolutely normal. 



PLATE I 




Achondroplasia. 

Expanded diaphyseal ends and epiphyses with very short shafts. The 
arms and legs are much shorter in proportion than the trunk. The upper 
arms and the thighs are proportionately shorter than the forearms and the 
legs below the knees. 



CHAPTER VIII. 
INFANT FEEDING. 

Cow's Milk. — The infant may be fed on cow's, goat's or ass's milk, 
but as the milk of the cow is almost always obtainable, and that of 
the ass and goat is often difficult to procure, cow's milk is, for practical 
purposes, the one which is universally adopted in the United States. 

Our first thoughts in regard to cow's milk should be of the cows 
and the farm. The herd should be healthy and free from any taint 
of tuberculosis. They should be properly fed both in and outside of 
the barn, and care should be taken to see that the pasture fields do not 
contain weeds and rank growths. The cows should be carefully 
groomed, given an abundance of fresh air and fresh water, and the 
manure should be removed from the barn as frequently as possible. 

The milkers should be clean, and, if milking is done by hand, the 
milkers should wash their hands just before milking, and the milk 
be received into the pail in such a manner as to avoid any contamina- 
tion from the cow's udder The first few streams of milk which flow 
from each teat should be thrown away, as this contains the major 
portion of the bacteria. 

The milk should be cooled to 45° F. within an hour after milking, 
and kept at or below this temperature until it reaches the consumer. 

Much could be written about the production and care of milk, 
but space does not permit. It is, however, the plain duty of every 
physician to familiarize himself with the production of milk as seen in a 
model, modern dairy, and to urge upon all those with whom he comes 
in contact professionally the importance of a good and unvarying 
milk supply. All milk used in infant feeding should be fresh and clean, 
should contain no pathogenic organisms or preservatives, and its 
chemical composition should vary from day to day as little as possible. 
Unless the percentages of fat, protein, and sugar remain fairly constant, 
it will be impossible to give to the infant, whose bottles are prepared 
from this milk, the same milk mixture each day. 

If the herd is properly cared for on a modern farm, there is less 
variation in the mixed milk of the herd than is noted in the milk of a 
single cow. For this reason it is wiser to use mixed milk from a herd 
of cows rather than the milk of a single cow. The milk from one cow 
is often, however, used with the very best results in feeding one or 
more infants, but one should be certain that the cow receives every 
requisite care and attention. 

The chemical composition of the milk will vary according to the 
breed. Holstein cows produce a large amount of milk with an average 
composition of fat 3 per cent., sugar 4 per cent., proteins 2.8 per cent. 



142 INFANT FEEDING 

Jersey cows usually give less milk, but the fat will often average 5 
per cent., sugar from 4.5 per cent, to 5 per cent., proteins 3.65 per cent. 

The milk from a herd of healthy, but common, varieties of cows is 
to be preferred to that of high bred or fancy stock, simply because 
the high bred animal is often delicate and susceptible, therefore more 
sensitive to its surroundings, and more apt to become temporarily 
sick or diseased than are the hardier herds. 

The average composition of the milk of such a herd is as follows : 

Fat 3.5 to 4.0 per cent. 

Sugar 4.0 to 4.5 " 

Proteins 3.5 to 4.0 

Ash 0.7 to 0.8 

AVater 88.3 to 86.7 



100 to 100 



The importance of securing a clean, raw milk, of definite chemical 
composition, free from pathogenic organisms, containing not more 
than 10,000 bacteria per cubic centimeter, and no preservatives, is 
readily understood and appreciated. 

It is, of course, apparent that to produce such milk entails much 
additional expense to the dairy owner, and, of course, an extra high 
price to the consumer. Dairies capable of producing such a product, 
which is commonly called "certified milk," are now established near 
almost every large centre of population, and, in fact, in many small 
communities the additional price which certified milk brings to the 
producer has been a sufficient stimulus to make an energetic dairyman 
develop a model farm. 

In some large cities, as Philadelphia, a number of such model dairy 
farms have been established, and the resulting competition keeps the 
standard high, and the public is, consequently, all the better protected. 
In order to maintain the standard of certified milk, it is customary to 
have samples bought in the open market, and examined by competent 
chemists and bacteriologists who are selected by a local Milk Com- 
mission to whom they make their report. 

Bacteria in Milk. — Milk is one of the best culture media for bacteria, 
although their growth depends largely on the temperature. Milk 
kept at 45° F. will show very little bacterial growth; at ordinary 
summer heat, 70° to 90° F., the growth is rapid. All milk contains a 
certain number of bacteria, and a low bacterial count, such as 10,000 
per cubic centimeter, is the usual standard for certified milk. 

There are, as a rule, fewer bacteria in milk bottled at the farm than 
in milk transported in large cans from the dairies, and sold to the 
consumer from the cans. A milk that does not contain more than 
50,000 bacteria in winter and 100,000 in summer per cubic centimeter 
is generally considered good milk. 

Cream usually contains a much higher bacterial count than milk. 
In gravity cream, especially, the bacterial count is high, as, apparently, 
most of the bacteria are carried by the fat globules to the upper cream 



COW'S MILK L43 

layers. Centrifugal cream contains less dirt and bacteria than gravity 
cream. The number of bacteria within certain limits is, however, 
not a matter of vital importance, provided that no pathogenic bacteria 
are present. 

If, however, the bacterial count is only 10,000 or 20,000 per cubic 
centimeter it points to the fact that the conditions under which the 
milk is produced are exceptionally good; consequently it indicates 
less probability of pathogenic organisms being present. The cleanliness 
of the cows, the barn, and the milker, the fact that no dry fodder is 
fed to the cows before milking, and no sweeping permitted — both of 
which produce dust — and the careful wiping with a wet cloth of the 
cow's body, especially its udder, just before milking, are important 
aids in the reduction of the bacterial count. 

The sterilization of all milk containers, the straining of the milk 
through sterilized cloths, and its rapid cooling, with absolute cleanliness 
of the milkers, are also factors which assist in reducing the bacterial 
count. The custom of bottling milk at the dairy is an excellent one, 
and that of serving all milk to the houses of consumers in bottles 
most important. 

If the cow's udder is diseased, pyogenic organisms may be found in 
the milk, or the germs of tuberculosis, anthrax, or foot or mouth disease 
may enter the milk directly from the cow. The menace to public 
health when cows, are infected by these diseases, and the danger of 
transmitting them by means of their milk, as well as the danger of 
infecting other cows, are now quite generally appreciated, and State 
laws are being made more and more stringent. 

Of the pathogenic bacteria found in milk the most important is the 
typhoid bacillus, which, being water-borne, may gain access to the 
milk in many ways, especially through an infected milker, or by using 
infected water for cleaning cans and diluting the milk. Diphtheria 
and scarlet fever may be spread by milk, commonly through some one 
who has the disease, and is employed in the dairy. 

The putrefactive bacteria in milk act on the proteins and may form 
toxins which, being taken by the infant with its milk, may cause 
dangerous symptoms; or, again, certain putrefactive bacteria may 
develop rapidly in the intestinal tract of the infant, especially if the 
child has intestinal indigestion, and often produce severe or even 
dangerous symptoms. 

The Souring of Milk. — This is caused by the lactic acid-producing 
group, and the rapidity of their growth is increased by the milk sugar. 
At the stage of souring they form 90 per cent, of all bacteria present. 

The Preservation of Milk. — Milk, when it reaches the consumer, is 
usually a mixed product, a part of it twelve hours old, the other part 
twenty-four hours old. This milk is usually the day's supply for the 
household, so that, by the time it is used, some of it is forty-eight hours 
old. If the milk comes from a first-class dairy, where absolute cleanli- 
ness is insisted upon, and the milk is, immediately after milking, 
removed from the milking barn, and rapidly cooled to 45° or 50° F., 



144 



INFANT FEEDING 



and kept at this temperature until it reaches the consumer, it ought 
to be fresh and sweet. When consumed this milk should not have a 
bacterial count above that which is considered safe. 

Now, as a matter of practical every-day experience, we know that the 
major portion of the milk sold is not produced in these model dairies, 
and it is difficult to enforce strictly those regulations that require 
the milk to be kept cool until it reaches the consumer, although much 
has been done by law to insure the keeping of milk at a low tempera- 
ture during transportation. 

The problem is, how is this ordinary market milk to be preserved? 
It can be said without hesitation that it is most unwise to add to the 
milk any chemical preservative whatsoever. The use of formaldehyde, 
salicylic acid, or any other preparation for this purpose should be 
forbidden by law. Given a milk which we believe to be unfit to feed 

to an infant or child, we can by the 
application of heat largely destroy the 
bacteria present, and by keeping it as 
cool as possible after this heating tend 
to prevent the subsequent growth of 
bacteria and, also, its becoming sour. 
In other words, we may sterilize or 
pasteurize such milk. 

Sterilization. — By sterilization we 
mean the heating of milk to the boil- 
ing point, 212° F. or 100° C. This is 
most easily accomplished by the use 
of an Arnold steam sterilizer. The 
milk should be kept at 212° F. for 
twenty to thirty minutes, and then 
rapidly cooled by placing the bottles in 
the rack under cool running water, and 
then setting them on ice. The rapid 
cooling is important, as it prevents 
the separation of the fat globules. 
Among the very poor and ignorant, it is impossible to have the milk 
kept on ice after it has been sterilized for the usual twenty or thirty 
minutes. In such cases it is easier to sterilize the milk for one hour, 
as such milk, if kept in well stoppered bottles, will not turn sour, and 
will show no increase in the growth of bacteria for twenty-four hours 
or longer. If an Arnold sterilizer is not available, the bottles of milk 
may be placed upright in a vessel containing warm water, and this* 
water may be boiled for twenty to thirty minutes. 

Among the poorer classes the day's supply of milk may be placed in 
a large corked jar, the jar placed in water, and the water boiled for the 
requisite number of minutes. Sterilization in this manner will destroy 
all pathogenic bacteria, and practically all of the other bacteria, but it 
will not destroy the spores, and these spores may subsequently develop 
into bacteria. 




Fig. 21. 



-Arnold steam sterilizer. 
(Abbott.) 



COW'S MILK 145 

When the milk supply is poor the need of sterilization is self-evident. 
Not only does it destroy the bacteria, but it provides for the children 
of the poor a milk that is safe to be used in hot weather, and requires 
very little intelligence or time for its preparation or subsequent care. 
Even for sterilization, however, as clean a milk as possible should be 
procured, since the spore-bearing bacteria are not destroyed; they 
may, when they develop, act upon the protein of the milk and not 
upon the milk sugar. Such milk may be capable of producing severe 
toxic symptoms, and yet be considered safe, since it may not be sour. 
Sterilization tends largely to prevent the appearance of casein curds 
in the stools; but, if already present, it is one of the best methods 
for getting rid of them. 

Sterilization makes it possible to feed cow's milk to a large number of 
children among the poor who would otherwise be made ill by the milk, 
consequently are fed on poor substitutes, such as barley water, albumin 
water, condensed milk, and proprietary infant foods. 

Yet this process is advisable only when the milk supply is unsatis- 
factory, as it produces changes within it that are undesirable, and all 
its protective properties, such as ferments, alexins, antitoxins, and 
agglutins are destroyed. The taste of the milk is altered, and on this 
account some infants will not take it readily. It is also more con- 
stipating; but, as sterilized milk is usually given in summer, this is of 
little consequence. The milk sugar is partly changed into caramel, 
the lecithin and nuclein are decomposed, the organic form> of phos- 
phorus are reduced, the lactalbumin is, at least, partially coagulated, 
the emulsion of the fat is altered, the action of rennet upon the casein 
is affected, and oxygen, nitrogen, and carbonic acid gases are expelled. 
In a considerable proportion of the cases scurvy has been shown to 
have developed in children fed on sterilized milk. 

Pasteurization. — In order to avoid the disadvantages of sterilization, 
and at the same time obtain all the benefits which it affords, a tem- 
perature was sought which would be below the boiling point, 212° F., 
and yet would destroy pathogenic and other bacteria. It has been 
positively demonstrated that pasteurization, or the heating of milk 
to 150° to 157° F. (65° to 69° C), will accomplish this. The milk is 
kept at this temperature for twenty to thirty minutes. It is then 
cooled rapidly by placing the bottles in cold running water, and they 
are then immediately placed on ice or in a refrigerator, so that the 
temperature will not rise above 45° F. 

Pasteurization produces no important chemical or biological change 
in the milk, and its taste is very little changed. The pathogenic and 
other bacteria in the pasteurized milk are destroyed, but the spores 
are not. The lactic acid-producing bacteria, which cause the souring 
of milk, and are present in considerable numbers in fresh milk, are 
also destroyed, consequently the tendency of pasteurized milk to sour 
is lessened. The presence of the lactic acid group also tends to prevent 
the development of other bacteria. 

In pasteurized milk the lactic acid bacteria are destroyed, but the 
10 



146 



INFANT FEEDING 



development of the spores is not checked or hindered by either the 
pasteurization or lactic acid, and the development of these spores is 
liable to proceed unchecked. It is important, therefore, to use pas- 
teurized milk within twenty-four hours, as the destruction of the 
lactic acid group prevents the milk from turning sour, and also favors 
the development of spore-bearing bacteria. 

The putrefactive group that affect the protein may develop rapidly, 
yet the fact that the milk does not turn sour may give one the impres- 
sion that it is safe for the infant. 

The best method of pasteurizing milk is by the use of the Freeman 
pasteurizer. This is uncomplicated, reliable, and not expensive, and 
the use of a thermometer insures accuracy in the temperature to which 
the milk is raised. During the hot summer months pasteurization is 
an additional protection to the infant, but it should be done in the 
home of the child; since if milk is pasteurized at the farm, twenty-four 
hours before it reaches the consumer, the dangers to the infant may be 
increased rather than lessened. 





Fig. 22. — Freeman pasteurizer. 



Fig. 23. — Freeman pasteurizer. Recep- 
tacle raised for cooling. 



Heating does not destroy the toxins that may be present in the milk, 
but it does destroy the bacteria, and checks their subsequent growth. 
Therefore, it is not safe to assume that either pasteurization or 
sterilization compensates for uncleanliness, or can make an unclean 
and toxic milk safe food for an infant. 

Concerning the Feeding of Sterilized, Pasteurized, or Raw Milk. — The 
only reason for sterilizing or pasteurizing milk is because it is feared 
that, if fed to the infant raw, it will make the child ill. In deciding then, 
in a particular case, whether the milk should be heated or not, and, if 
heated, whether it should be pasteurized or sterilized, the question 
depends primarily on certain factors — the freshness of the milk and the 
number of bacteria it contains when it reaches the consumer, also 
whether or not it has been kept at 45° to ,50° F., and the probability 
of its contamination after it reaches the consumer. 

Another important factor is whether the season is summer or winter. 
Among the poor, especially in cities, the milk they can afford to buy 



COWS MILK 147 

is always twenty-four hours old, contains usually a large number of 
bacteria, and is not kept at a low temperature — 45° to 50° F. — after 
they receive it. Moreover, if their surroundings are uncleanly, the risk 
of contaminating such milk is very great. 

ruder such circumstances, it is safer for the infant if the milk is 
sterilized for one hour, and this can be accomplished by boiling the 
milk in any suitable vessel, preferably a double boiler, pouring it into 
a clean quart jar, corking it tightly, and keeping it in the coolest place 
available. Such milk will keep for at least twenty-four hours, often 
longer, and is, under the circumstances, safer than when pasteurized. 

When infants are fed for any considerable period on sterilized milk 
it is always wise to give them a small amount of fresh orange juice 
every day or two, as it is a well known clinical fact that many cases of 
scurvy develop in infants who are fed on sterilized milk. 

In the feeding of infants in hot weather all milk that is not " certified" 
should be pasteurized except when the supply of milk is produced 
close to the consumer and under exceptionally sanitary circumstances, 
is cooled immediately after milking, and receives proper care after it 
reaches the consumer. 

It is, in my opinion, much safer in hot weather to pasteurize all 
milk concerning which there is, in the mind of the physician, the 
slightest doubt. The heating of the milk to 1 ~)7° F. practically makes 
no change in its chemical or biological composition, and children 
digest it well, and show a satisfactory gain in weight and development. 
It must be remembered, however, that pasteurized milk should not be 
kept longer than twenty-four hours, and must always be kept coo). 
It is true that at a temperature of 70° C. a portion of the lactalbnmin 
and lactoglobulin is coagulated, but the nutritive value of such change 
is apparently very slight. 

The sterilization or pasteurization of milk destroys the pathogenic 
bacteria of tuberculosis, typhoid fever, and diphtheria, also the 
streptococcus, staphylococcus, and bacillus coli communis. It is also 
of assistance in the treatment of the gastro-intestinal infections of 
infants and children. It does not, however, lessen in any degree the 
necessity of properly modifying the milk to adapt it to the age and 
digestive capabilities of the infant. 

When May an Infant be Fed Raw Modified Milk? — Personally, I 
feed many infants oil raw modified milk in summer as well as in winter. 
If a "certified milk" is accessible, and one is sure that this certified 
milk is only twenty-four hours old, or even less, and has been kept at 
4:5° to 50° F. or lower since it left the dairy; if the consumer can give 
this milk the best care as to home modification, icing, and freedom from 
contamination, then I see no reason why the infant should not be fed 
on raw r certified modified milk. Among the intellligent and well-to-do 
the importance of a clean, fresh milk with low bacterial count is quite 
generally appreciated; and, if the mother is properly instructed by 
the physician, the results of such feedings are very satisfactory. If, 
however, there is any doubt that the various steps in the preparation 



148 INFANT FEEDING 

and care of this milk will not be properly carried out, then it is much 
safer, even with certified milk, to pasteurize it, particularly in summer. 

Peptonization. — Peptonized milk is of service when an infant is 
unable to digest sufficient milk to make it gain in weight. It must not 
be understood that every child that does not gain in weight should be 
fed on peptonized milk; but by its use a larger amount of food may 
•often be given, and the digestion and absorption of this food be 
rendered less difficult for the stomach and intestines. 

The object of peptonizing is partially or completely to digest the 
protein before feeding, consequently to give the child a higher protein 
percentage than would be possible without its use. One may use the 
peptonizing tubes on the market, which contain five grains of the 
extract of pancreatin and fifteen grains of bicarbonate of soda, or may 
order this amount put up in waxed paper powders. 

If one of the powders is dissolved in four ounces of cold water, and 
this added to one pint of fresh milk which is placed in water at a tem- 
perature of 110° F., peptonization begins at once, and may be con- 
tinued as long 'as desired for each individual child. If the milk is 
removed after twelve minutes, and immediately placed on ice, further 
peptonization is checked, and the milk is unaltered in taste. If kept 
in the warm water for twenty (20) minutes, it usually becomes so 
bitter that many infants will not take it readily. 

Peptonization does not interfere in any way with the modification 
of the milk, or make it undesirable or unnecessary to use modified 
milk. The amount of peptonizing powder added is regulated by the 
amount of milk used at each feeding. Since peptonization takes place 
only in an alkaline medium, the bicarbonate of soda must always 
be added. This milk is useful in premature and delicate infants as 
an aid to digestion, also in convalescence from acute and chronic 
gastro-intestinal diseases, when it is desirable to give the infant milk, 
and one more or less doubts its ability to digest it. 

It is often, in my experience, possible to give the infant so fed a 
larger amount of milk if it is partially peptonized, then if there is a gain 
in weight the amount of powder can be gradually reduced until, in 
the course of a few weeks, it may be entirely omitted. The fact that 
the digestive organs of an infant will develop and acquire the power 
perfectly to digest cow's milk, if the infant is healthy and properly 
fed, is well known, and this fact is often used as an argument against 
peptonization, which reduces the normal work of digestion; but pep- 
tonization is advised only in those cases where the digestion of the 
child is temporarily poor, and as the child improves it is gradually 
discontinued. 

Completely to peptonize modified milk requires that the bottles 
be kept in water at a temperature of 110° F. for one hour. This milk 
may be used in feeding by gavage those infants who can not, or will 
not, take enough food properly to nourish them. 

In giving nutrient enemata to infants, skimmed milk should be used. 
A linen or silk catheter, full male size, should be well oiled and gently 



COW'S MILK 1 19 

passed about 7 or 8 inches up the rectum, and the m ilk, at a tempera- 
ture of 100° .F., be allowed to How gently into the bowel. About tbe 
same amount of food should be given by rectum as would be suitable 
for a bottle feeding; this amount, of course, depending on the age of 
the infant. 

The child should lie on the left side with the buttocks elevated, and, 
if possible, the enemata should be given without causing any fright or 
nervousness. They should not be repeated oftener than every six or eight 
hours, and while they are being given the lower bowel should be irri- 
gated once daily with normal salt solution. As a rule, this method of 
feeding cannot be continued more than a week or ten days, as the 
rectum is apt to become irritable and the enema is quickly expelled. 

Diluents — Water. — In order to reduce the 4 per cent, protein in 
cow's milk to a percentage that the infant is able to digest, it is neces- 
sary to add to the milk a diluent, and the most common diluent is 
water. The amount of water can be regulated so as to produce any 
desired reduction in the protein. The protein of cow's milk is not 
only greatly in excess, as compared with breast milk, but the protein 
in cow's milk has a tendency to form large curds in the infant's stomach, 
and these are more difficult to digest than the finer flocculi produced by 
the protein in human milk. 

Cereal Diluents. — Cereal decoctions act mechanically, and break 
the coagulable proteins up into finer particles than is usual when plain 
water is added. Any of the cereal decoctions, as prepared on page 157, 
may be used, and by reference to this table one may sec exactly the 
amount of starch that is to be added. If the infant is young, dextrinized 
gruels are preferable, as the functions of the salivary glands and 
pancreas, which are only partially established in the young infant, 
are thus compensated for. 

The preparation of dextrinized gruel is very simple. A teaspoonful 
of liquid diastase, or five grains of taka diastase added to a quart of 
any of the cereal gruels after they have been prepared, converts the raw 
starch into soluble carbohydrates. The cereal decoction should be 
stirred after the diastase is added, and as the starch becomes dextrin- 
ized the gruel becomes thinner. The diastase is added after the 
gruel has cooled sufficiently to be tasted. After it becomes thin by 
the addition of the diastase, it should be strained, and then kept 
cold. 

One of the best preparations of diastase to use for dextrinizing 
gruels is called cereo. Half a teaspoonful of cereo is sufficient for one 
pint of gruel. In the infant of six months or older the starch digestive 
function is sufficiently developed to render dextrinization unnecessary. 
The most common form of cereal diluent is barley water, and, if there 
is any vomiting or diarrhea, it is the one to be preferred. Oatmeal 
water, being slightly laxative, is to be selected if there is constipation. 
The digestion of protein is rendered less difficult by the addition of 
cereal diluents, probably owing to the finer protein curds which they 
form. 



150 INFANT FEEDING 

Alkaline Diluents. - The alkaline diluents commonly used are lime- 
water and bicarbonate of soda water. It is a matter of clinical 
experience that the addition of either of these alkalies is of service 
in infant feeding, and their beneficial effect is due to the fact that they 
tend to retard the action of the rennet ferment in the stomach on the 
casein. Any lactic acid which may be present in the milk is also 
neutralized by the alkali added, and, by their action in partly neutral- 
izing the normal acids of the stomach, they lessen the tendency of the 
casein to form in large curds. 

Lime-water is the alkaline diluent commonly employed, and is 
usually added in the proportion of 5 per cent. — one ounce of lime-water 
to every twenty ounces of food mixture. The effect of the lime-water 
is in direct proportion to the amount of cow's milk in the food. If the 
percentage of milk is large, the effect will be much less than if, as in the 
feeding of young infants, the percentage of milk is small. 

Acting, as it does, on the protein to prevent the clotting action of 
rennet in the stomach, the formation of clotted paracasein is delayed, 
and the masses formed are, therefore, smaller. It is evident that, 
if large amounts of lime-water are added to very weak milk mixtures, 
the clotting of the milk in the stomach is largely prevented, and the 
milk will pass into the intestine but little affected by the acids of the 
stomach. 

Next to lime-water, bicarbonate of soda is the alkali most commonly 
added to the diluent, usually in the proportion of one grain to each 
ounce of the food mixture. If, however, it is added in the proportion 
of two grains to each ounce, it tends, as do larger amounts of lime-water, 
to prevent the clotting of the casein by delaying acid formation in the 
stomach. 

CONDENSED MILK. 

Condensed milk consists of cow's milk which has been first sterilized, 
and then evaporated in a vacuum. Cane sugar is then added, and the 
preparation is hermetically sealed in tin cans, or sold fresh and 
unsweetened. 

Condensed milk contains, even when diluted with six parts of 
water, only a little over 1 per cent, of fat and protein, and more than 
7 per cent, of sugar. In feeding young infants it is often diluted twelve 
or fourteen times with water, so that all of these percentages are reduced 
to one-half of the above. Now if, for any particular reason, it is 
advisable to feed an infant on these low percentages, condensed milk 
may be used with advantage. 

It is, of course, at once apparent that condensed milk, being so weak 
in fats and proteins, is poor nourishment for an infant. The child, if 
fed continuously upon it, owing to its ability to digest sugar, may 
gain in weight and become quite fat, but its tissues are soft and 
flabby, it cuts its teeth late, its bones fail to develop properly, it is late 
in creeping and walking, and becomes rachitic and anemic. 

The great objection to condensed milk is that (unless one bears in 



THE FOOD MATERIALS USED IX INFANT FEEDING 151 

mind the necessity of a proper amount of fat and proteins in the 
did and the dangers of a deficiency of these food materials) because 
the baby looks fat and well it may be allowed to remain too long on the 
condensed milk. Under certain circumstances, as a temporary food, 
condensed milk is valuable. 

Among the poor, especially in large cities where it is impossible for 
them to procure good milk, or when, owing to ignorance or carelessness 
they cannot prepare good cow's milk properly or keep it after its 
preparation, condensed milk is often the safest and best food, espec- 
ially during the hot summer months. It is cheap, easily prepared, 
each feeding is made ready at the time of feeding, so that the bottle 
and nipple can be cleaned each time, and it is sterile. 

It is also often very satisfactory for young infants during a few days 
when travelling, or when the supply of fresh cow's milk is uncertain or 
unsatisfactory, and it is of use sometimes for young infants who are 
suffering from acute indigestion, especially, in my experience, when they 
have been fed excessive amounts of fats, and are suffering from acute 
fat indigestion. Such babies usually take it greedily, owing to its sweet 
taste, and it is often retained when modified cow's milk is vomited. 

As the infant's digestion improves, the proportions should be 
gradually reduced from twelve parts of water and one part of condensed 
milk to six parts of water and one part of condensed milk: cream 
should then be added, a teaspoonful to each feeding, and this gradually 
increased to a tablespoonful at each feeding, and then the infant is 
placed upon weak modified milk mixtures. 

THE FOOD MATERIALS USED IN INFANT FEEDING. 

An infant may be fed in one of three ways: By its own mother, 
which, if she has a suitable supply of breast milk, is to be preferred; 
by a wet nurse, which, if certain precautions are taken as regards her 
health and her ability to secrete a normal amount of breast milk of a 
certain quality, is undoubtedly the next best method; or the child may 
be raised on the bottle. 

The raising of a child on the bottle is at all times a responsibility 
which is not to be assumed by the physician unless he has devoted 
much time and thought to the study of infant feeding. If the child is 
placed in the hands of a skilled pediatrist immediately after birth, or as 
soon as it is decided that it requires food other than breast milk, the 
difficulties encountered are often slight and the disturbances of the 
gastro-intestinal tract are usually mild. 

If, however, it is poorly nourished and has had more or less severe 
gastro-intestinal disturbances for weeks or months, its subsequent 
feeding on the bottle becomes one of the most difficult tasks of the 
pediatrist; and while the final result is almost invariably favorable, 
one must expect to encounter, during the period of feeding, relapses 
and setbacks which, being looked for, will not discourage the physician 
who has thoroughly studied and understands his subject. 



152 INFANT FEEDING 

It must be well understood at the outset that infant feeding is a 
difficult problem and that it is a very broad and important subject. 
It includes the feeding of the infant in sickness and in health. It is 
intimately connected with the problems of etiology and diagnosis, and 
is linked with many other associated factors, as heredity, environ- 
ment and fresh air. The food which is provided by each mammal for 
its young is particularly suited to develop its digestive organs as 
well as the rest of its body, and is always animal and never vege- 
table. 

During this early nursing period of child life, it seems, therefore, 
normal for the food to be in animal and not vegetable form. It is also 
highly important that the digestive powers and possibilities of the 
infant be carefully studied and understood, and only such food given 
as the child is able to digest. It is important to remember that while 
cow's milk is usually the best artificial food for an infant, it was 
intended for the stomach of the calf and not for the stomach of the 
infant. It is, therefore, safe to give this cow's milk only after the power 
of the infant to digest it is thoroughly understood. 

Infant feeding is one of the most important departments of pediatrics. 
The problem is not alone to provide suitable food in the proper pro- 
portions to sufficiently nourish the infant, but it is important that all 
the different tissues of this rapidly growing organism be appropriately 
nourished. 

The infant's increase in weight and length is so unusual as compared 
with any other period of life, that the problem of its feeding differs 
radically from what one meets with in adult life. The adult requires 
sufficient food to keep his body in a state of equilibrium. The young 
child must have food, not only to nourish his body, but an extra amount 
to produce the very remarkable increase in growth that occurs at this 
period. 

Now if it were simply a question of giving the infant a large amount 
of milk, the matter would be a very simple one. Unfortunately, 
instead of being such a simple task as this, the problem is often a 
complex one, and the difficulties are much increased when, instead of 
being fed on the breast, the infant is being raised on the bottle. 
The gastro-intestinal apparatus of the infant is extremely delicate, 
complicated, and sensitive. It is easily disturbed by influences that 
are often difficult to appreciate and guard against, and if any disturb- 
ance of digestion is allowed to continue for more than a short period, 
it often complicates, to an excessive degree, the question of its food. 

The study of infant metabolism clearly shows that there is a con- 
tinuous using up of the body tissues, and that to replace these tissues 
and in addition to cause an increase in their growth, requires that the 
child be fed not only a certain amount of food which it can digest, 
but also a food ration so well balanced that the different require- 
ments of the various tissues may be so amply met that the baby will 
develop along well established and normal lines. 

To produce gain in weight by a food that does not possess the proper 



THE FOOD MATERIALS USED IN INFANT FEEDING 153 

proportions of the various food elements must always be considered as 
a temporary expedient, perhaps useful and necessary for the time 
being, but never to be persisted in long enough to produce anemia, 
malnutrition or rickets. Unfortunately, the ill-effects of such feeding 
may not be apparent for weeks or months, and are easily overlooked, 
especially if the child is gaining in weight. Many of the foods of this 
character possess a high percentage of carbohydrates and often a low 
proportion of fat and protein. 

If there is one factor in infant feeding that is more important than 
another, it is the appreciation of the fact that the regular nourish- 
ment of the infant must contain certain food elements in more or less 
definite proportions. These proportions are not absolutely fixed 
percentages, but they can vary only within certain broad limits, and 
it is most unwise either greatly to reduce one or markedly increase 
another food element, unless there be, temporarily, some very good 
and sufficient reasons. 

There are certain laws of physiology which make it imperative that 
a definite amount of food be given the infant, and, further than this, 
the food must be composed of fairly accurate amounts of the different 
food ingredients. If the principles that underlie infant feeding are 
well understood and adhered to, many of the more common errors of 
feeding will be avoided. 

The child's body is composed of protein, fat, water and mineral 
salts, and is constantly undergoing a process of waste. This loss must 
be replaced by the food elements, and the principles of nutrition that 
underlie the replacing in the child's body of this continuous using up 
of its own body cells, are the first facts of infant feeding which the 
student and physician must appreciate. It is important, therefore, 
that we understand the part that the different food elements perform 
in the replacing of the loss of the body tissues. These food elements 
are water, protein, fat, carbohydrates, and mineral salts. 

Water. — The infant's body is composed of about 68 per cent, of water, 
and it is, therefore, only natural that in building up this infant's body, 
or, in fact the body of any young mammal, a large percentage of 
the nourishment taken should consist of water. The various food 
elements are dissolved or suspended in this water and the food is 
consequently always in a liquid form. The water also serves the 
important function of eliminating the waste products of the infant's 
economy, and it is estimated that to meet the various demands of the 
infant, five times as much water is required, in proportion to its weight, 
as is needed by the adult. The common practice of giving a child 
water to drink between its feedings, especially in summer, is, therefore, 
a good one. 

During illness, when the amount of fluids lost by the body is great, 
or when toxemia exists, the administration of large quantities of water 
is most important. In fact, water, being present in such a very large 
proportion in both human and cow's milk — 86 to 87 per cent. — is 
evidently the most important single food ingredient, and if it can be 



154 INFANT FEEDING 

given in fairly large quantities will assist materially in maintaining 
body weight, especially in gastro-intestinal disease. 

The absence of the other food elements for more than a few days is, 
however, a great disadvantage to the body tissue, and results in their 
rapid wasting. The water carries the nourishment, by the various 
blood and lymphatic vessels, to every organ and tissue in the body, and 
by carrying off waste products through the skin, bowels, kidneys and 
breath, prevents the development of auto-intoxication. 

Protein. — Protein is an important element in the food, and is that 
portion of the diet which replaces the nitrogenous waste of the tissues. 
It is also that element in the diet that is capable of building up new 
cells in the various organs and tissues, and as the growth of the infant's 
body is unusually rapid a proper amount of protein is absolutely 
essential if this growth is to be maintained. 

In order that the protein may be utilized for its purpose of cell- 
building, it is necessary that the fats and carbohydrates be given in 
sufficient amount to produce all the heat and energy that the infant's 
body may require. If this requisite amount of carbohydrates and fats 
is not given, an excessive amount of protein is necessary to produce 
the bodily heat required. 

By supplying this fat and carbohydrate in the diet, not only is the 
normal animal heat of the body preserved, but they make it unneces- 
sary for the protein to furnish this energy and heat, and the protein is 
then capable of performing its normal function of cell upbuilding. 

There is, however, a decided difference between the protein of human 
milk and cow's milk. Human milk contains 1.5 per cent, protein, 
of which lact albumin forms from one-half to two-thirds of the total 
protein. Cow's milk contains 3.5 per cent, protein, of which casein 
forms two-thirds of the total protein. It is at once evident that not 
only is the protein present in much larger amounts in cow's milk than 
in human milk, but the proportion of casein is also much greater. 

It has been shown by Chapin that each mammal furnishes an 
animal food which is peculiarly adapted to the digestive organs of 
its young, therefore we can not doubt that the lactalbumin in 
mother's milk is easier for the infant to digest than is the casein 
of cow's milk. It is, however, equally true that we have formerly 
exaggerated the difficulties that infants have in digesting casein, and 
that it is not nearly so hard for the infant to digest it as we formerly 
supposed. 

In fact, it is not difficult for the infant stomach to digest cow's 
casein, if it is not thrown down in the stomach in large clots. If this 
large clot formation can be prevented, cow casein is digested by the 
infant with very little difficulty. This can be accomplished by adding 
to the cow's milk, before it is given to the infant, an alkali, as lime 
water or bicarbonate of soda, or an acid, as dilute hydrochloric acid. 
Either the acid or the alkali will combine with the casein and, since 
rennet can act only in a slightly acid medium, will prevent the casein 
from forming large clots. 



THE FOOD MATERIALS USED f\ INFANT FSEDING 155 

Fats. In the healthy breast-fed or bottle-fed infant, fat is always 

found in the stools, and its presence renders the stools less hard and 
dry. The total amount of fat in the food of the infant at the breast 
is not, therefore, utilized entirely for its food value. A certain amount 
of fat cleavage begins in the stomach, and fatty acids and soluble soaps 
are produced in the intestinal canal. 

The bile affords a medium for the solution of free fatty acids, and, 
to a certain extent at least, fats are transformed into soluble forms 
before being absorbed. The rapidly growing infant requires a pro- 
portionately larger amount of fat than docs the older child or adult. 
This fat, which in human and cow's milk is present in the proportion 
of 4 per cent., has a very complex composition. 

Moreover, fat metabolism is a complicated process which is not yet 
perfectly understood. There is a decided difference in the composition 
of human milk and cow's milk, and cow's milk is more difficult for the 
infant to digest than human milk. Cow's milk contains a smaller 
percentage of oleic acid and a larger percentage of volatile fatty acids 
than does woman's milk. 

The caloric values of the fat, protein and carbohydrates, according to 
Rubner, are as follows : 

1 gram of protein yields 4.1 calories. 

1 gram of fat yields 9.3 calories. 

1 gram of carbohydrate yields 4.1 calories. 

It is thus evident that fats are the chief source of animal heat, since 
their caloric value is double that of either proteins or carbohydrates. 
Although we must appreciate the fact that while fat is always present 
in the nursing infant's stools, only a portion of the fat in the food is 
utilized in metabolism. Fats do not build up the cells of the body as 
does the protein, but the fats and carbohydrates, by supplying the 
animal heat and energy to the body, save nitrogenous waste and allow 
the protein metabolism to be used for the growth and repair of the cells 
of the various organs and tissues. 

Fat deposits are found beneath the skin over practically the entire 
body surface and have an important function in increasing the body 
weight. They are also an evidence of health; a healthy baby is always 
a moderately fat baby. This fat supply is a valuable source of heat 
and energy during an illness when the supply of fat ingested may be 
much below normal. 

The nervous system, which shows such remarkable growth during 
infancy and which is composed largely of fat, requires a large amount 
of fat for its normal development. This is clearly shown in the impaired 
development of the nervous system if either the proportion of fat in 
the food is too small, or the child is suffering from prolonged fat indi- 
gestion. Fat also plays an important part in bony development, and 
rickets is often the result of fat starvation. Malnutrition and anemia 
are common conditions due to either too little fat in the food, or to 
poor fat digestion. 

The importance of fat in the diet of the infant may, however, lead 



156 INFANT FEEDING 

to its being given in excessive amounts. It should never exceed 4 per 
cent, in a milk mixture, and should always be reduced below the normal 
or usual amount for the age of the infant in acute gastro-intestinal 
diseases and febrile conditions; as infants with malnutrition are very 
apt to suffer from fat indigestion, the amount of fat in the food must 
be cautiously increased. 

Carbohydrates. — The carbohydrates in the form of milk sugar are 
present in human milk in the proportion of 7 per cent., and as milk 
sugar in cow's milk in the proportion of 4 per cent. The percentage of 
milk sugar in both human and cow's milk does not vary to any appreci- 
able amount during the period of lactation. Moreover, a chemical 
analysis of the sugar contained in human and cow's milk fails to show 
any differences that are of importance, and, further than this, the sugar 
in the milk of all mammals is this same milk sugar. 

In the feeding of cow's milk to infants, the regulation of the sugar 
content is brought about by simply adding the required amount of 
milk sugar to the cow's milk mixture. Milk sugar is less liable to 
undergo fermentation in the infant's stomach than is cane sugar or 
maltose. All three varieties — cane sugar, maltose and milk sugar- 
easily undergo fermentation in the intestines. 

It is a matter of clinical experience, however, that the milk sugar 
of cow's milk is especially liable to fermentative changes in the intes- 
tines. This is supposed to be due to the fact that the milk sugar 
contained in the whey protein of cow's milk is rendered less easy of 
digestion and assimilation; hence its greater tendency to fermentation. 

The carbohydrates represent the largest proportion of solids in 
human milk, and whether the infant be given carbohydrates in the 
form of milk sugar, maltose, or cane sugar, the percentage is usually 
the same, unless it is reduced because the infant has sugar indigestion. 
All three forms of sugar are changed into glucose by the digestive 
fluids. 

The newborn infant has very little ability to digest starch, and 
starch should not, as a rule, be added to the diet until the infant is 
six months old. After this age, the starch-digesting ability of the 
infant rapidly increases, and many bottle-fed infants are given starch 
in their food, after the eighth or ninth month. If one decides to give 
the baby some starch, it is absolutely necessary that the percentage 
of carbohydrates added to the food by this starch be exactly known. 
The addition of the starch adds no fat to the food and only a very 
minute amount of protein. 

The amount of starch in the different gruels varies according to the 
cereal employed, and whether the whole grain, cracked grain, or flour 
is used. Cereo gruel flour can now be purchased, and, by adding a 
certain amount of this flour to a fixed proportion of water, definite 
amounts of starch can be added to the infant's food. 

It cannot be too strongly emphasized that while starch is often 
advantageously added to the infant's diet, it should be added with 
the same accuracy as in adding to the fat or protein in the mixture, 



THE FOOD MATERIALS USED IX INFANT FEEDING 



157 



and as breast milk contains 7 per cent, carbohydrates, starch should 
not be added to the cow's milk mixture in such amount as to raise 
the carbohydrates above this 7 per cent. 

By the use of the standardized flours, it is possible to know the exact 
percentage of the proteins and carbohydrates added, and, knowing 
the exact percentage of the added gruel, one can easily calculate' the 
amount of protein and carbohydrates which the gruel adds to the milk 
mixture: 

PERCENTAGE OF PROTEINS AND CARBOHYDRATES OBTAINED BY THE 
USE OF STANDARDIZED FLOURS. 





( >at and barley. 


Legume. 


Wh< 




Pro- 
teins. 


Carbo- 
hydrate* 


Pro- 
tein.-. 


Carbo- 
bydratee 


Pro- 
tein-. 


Carbo- 
hydrates 


1 level tablespoonful to 1 quart water 

2 level tablespoonfuls to 1 quart water 

3 level tablespoonfuls to 1 quart water 
1 level coverful (1 ounce) to 1 quart 

water 


0.12 
0.24 
0.36 

0.48 


0.60 
1.20 
1.80 

2.40 

4.80 

7.20 

9.60 


0.19 

0.39 
0.58 

0.78 

1.56 

2.34 

3.12 


0.53 
1.06 
1.59 

2.12 

4.24 

6.36 

8. 18 


0.10 
0.20 
0.30 

0.40 

0.80 

1.20 

1.60 


0.62 

1 . 25 
1.88 

2 50 


2 level coverfuls (2 ounces) to 1 quart 
water 


0.96 


5.00 


3 level coverfuls (3 ounces) to 1 quart 
water 


1.44 


7 50 


4 level coverfuls (4 ounces) to 1 quart 
water < . 


1.92 


10.00 



The carbohydrates are easy of digestion and for this reason arc 
popular as infant foods. They are, however, as previously mentioned, 
liable to undergo fermentation, and hence carbohydrate indigestion 
is not uncommon. Infants fed on carbohydrates often increase rapidly 
in weight, but the flesh is soft and flabby and the infant is deficient 
in vitality and strength, and may be rachitic. 

The carbohydrates have an equal heat-producing power with the 
proteins. They are, to a certain extent, converted into fats, and so 
have a tendency to add to the infant's weight. They can not build up 
the cells of the body as does the protein, but by helping to maintain 
the body heat, storing up fat and supplying energy to the body cells, 
they are of great assistance to the protein. 

"The ordinary soluble carbohydrates are utilized to a high degree 
by the animal organism" (Hawk); and if the amount given is not 
above the power of the individual to assimilate, about 97 per cent, is 
utilized. The amount of cellulose utilized by the human digestive 
apparatus is "too small for it to play a role of importance in the diet 
of a normal individual" (Swartz). There is probably no formation of 
glycogen or sugar from ingested cellulose. 

• Mineral Salts. — The rapid growth of all the tissues and organs of the 
infant, especially of the bones, renders the ingestion and absorption 
of the mineral salts of great importance. 

Potassium, sodium, calcium, magnesium, phosphorus, and a trace 



L58 INFANT FEEDING 

of iron are the most important mineral salts found in milk. These 
salts, with the exception of iron, are present in sufficient amounts in 
both human and cow's milk to supply to the infant all that its body 
requires for normal growth and development. They are not, however, 
as a rule, found in sufficient quantities in the various foods often 
substituted for human or cow's milk. 

The deficiency of iron in the milk is compensated by the reserve 
store of iron which is found in the body of the infant, especially in the 
liver and spleen. The adult, in proportion to its weight, has only 
about one-third as much iron in the liver and other organs of the body 
as has the infant. The diet of the infant after the first year contains 
much more iron, and the iron requirements of the older child are 
accordingly supplied by the food as the quantity stored in the body 
has been largely utilized. 

According to the analyses of Harrington and Kennicutt, the mineral 
constituents in human milk are: 

Calcium phosphate 23.87 

Calcium silicate 1.27 

Calcium sulphate 2.25 

Calcium carbonate 2 . 85 

Magnesium carbonate 3.77 

Potassium carbonate 23.47 

Potassium sulphate 8.33 

Potassium chloride 12.05 

Sodium chloride ' 21.77 

Iron oxide alumina 0.37 

100.00 

Calcium phosphate is present in considerable quantity and is especi- 
ally necessary for the formation of the skeleton. The potassium salts 
are also present in proportionately large amount, and are especially 
utilized in the muscular tissue and red blood cells. The percentage of 
chloride of sodium is also large. The salts are an absolutely necessary 
part of the infant's food. They are essential for the performance of the 
numerous functions of cell activity and for the proper development of 
the nervous system. 

It is important, therefore, that the mineral salts be given in such form 
as is easily appropriated and used by the infant. This is best accom- 
plished by feeding the child either human or cow's milk. Mineral 
salts are present in definite amounts as important elements of all the 
fluids of the body, and are necessary for the proper performance of 
circulation, digestion, absorption, secretion, and excretion. 

Breast-feeding. — The best food for an infant is the milk from its 
mother's breasts. It is assumed, of course, that the mother is reason- 
ably strong and in fairly good health. If she willingly undertakes the 
duty of nursing her baby, it is of advantage. She should be relieved 
as far as possible from all unnecessary nervous strain and should use 
moderate care in her diet, exercise, and sleep. These precautions will 
all tend to increase the quantity and improve the quality of her milk 
and make it more likely that she will successfully nurse her baby. 



BREAST-FEEDING 1 59 

It is, therefore, necessary to inform the young mother who hopes 
and expects to nurse her child that it is important for her to do every- 
thing within reason to preserve her physical health and nervous 
energy, as otherwise she may unintentionally interfere greatly with 
her ability to nurse. After an experience of thirty years in the practice 
of pediatrics, I am persuaded that if the physician is ah enthusiast 
on breast feeding, he will almost always be able to convince the mother 
of the importance and necessity of nursing her baby. 

Breast-feeding must not be made too hard a task, and, occasionally, 
it may be wise to provide a bottle feeding once a day, for even a very 
young nursing infant. This allows the mother, on any day that 
she may desire it, a few consecutive hours for amusement or social 
pleasure. 

Mammary Gland. — The secretion of milk from the mammary gland, 
if the gland is healthy and the mother not disturbed by disease, worry 
or overwork, will almost invariably be a milk well adapted to the 
requirements of the growth and development of the baby. 

Its delicate mechanism, as yet only imperfectly understood, is very 
easily disturbed by illness, pregnancy, menstruation, worry, excessive 
fatigue, errors in diet, and many other causes, and the milk secreted 
may undergo many and various changes which may temporarily or 
permanently lessen its value as a food for the infant. 

The mammary gland is a self-regulating apparatus elaborating a 
smaller or a greater supply according to the demands of the infant. 
It is not only an organ of secretion but also an organ of excretion. *It 
is important to appreciate that certain drugs may be in part excreted 
by breast milk, and that during the colostrum period the milk differs 
distinctly from the milk secreted later. 

The child should be put to the breast as soon as possible, usually 
within three hours, after the mother has recovered from the strain 
and exhaustion of her labor. This early nursing accomplishes several 
important objects. It draws out the nipples, promotes uterine con- 
tractions in the mother, and tends to hasten the formation of milk 
in the breasts. 

Moreover, there is always in the infant an initial loss in weight, 
which means a corresponding loss in vitality, and this is at least lessened 
by giving the child a reasonable amount of nourishment during the 
first three days. During the first twenty-four hours the child should 
be applied four times to the breast; during the second and third 
twenty-four hours, six times; and after this every two hours from 

6 A.M. tO 10 P.M. 

It is true that during the first two days the child receives very little 
milk, and this colostrum milk differs greatly from the milk secreted 
later; but I certainly believe that this milk must be of nutritive and 
protective value, otherwise it would not always be present. If, 
during this preliminary feeding, the child is extremely restless and cries 
as if from hunger or thirst, sterile water may be given in two dram 
feedings three or four times a day. 



160 INFANT FEEDING 

Frequency of Breast-feeding. — The extremely rapid growth of the 
infant and the necessity of food to compensate for repair of waste due 
to its great metabolic activities necessitate the giving to the infant 
of more food proportionately than to the older child or adult. The 
infant requires 110 calories every twenty-four hours during the first 
four months of its life per kilo of body weight; 100 calories during 
the second four months per kilo; and during the third four months 
90 calories per kilo of body weight. 

During the night a healthy infant should never be awakened, 
but, if awake, it may be nursed twice at night during the first six 
weeks, between the age of six weeks and three months once or twice 
each night, and between three and six months the child should not 
receive more than one breast feeding between 10 p.m. and 6 a.m. If 
it awakes oftener, it should be given a bottle of water. 

A normal, healthy infant — if awakened every two hours from 6 a.m. 
to 10 p.m. during the first six weeks; every two and a half hours from 
the age of six weeks to three months ; and after this, every three hours 
— receives during the day a large amount of nourishment, and being 
awakened so often its sleep is more or less disturbed. It is only 
natural that this baby will require during the night — 10 p.m. to 6 a.m. — 
very little food and a good many hours of sleep. 

This regularity of feeding is of great practical importance; it secures 
regular hours of sleep for the mother, baby and the baby's nurse, and 
the infant, as a rule, quickly adapts itself to this routine and nurses 
willingly, sleeps well, and is quiet and happy. If the infant so fed is 
kept in the fresh air, not picked up when it cries, not rocked or fussed 
with, it rarely, unless sick, should be a source of great care or anxiety. 

Unfortunately, this systematic life, as regards feeding, bathing, 
sleep, fresh air and exercise, is often deliberately broken. The baby 
becomes nervous and fretful and cries because, having become accus- 
tomed to petting and rocking, it misses this attention. Such a baby 
may easily disturb the peace and routine of an entire household. 

The infant should be allowed to nurse from fifteen to twenty minutes 
at each feeding, the time being equally divided between both breasts. 
Some infants, especially if robust and nursing vigorously, and there is a 
plentiful supply of breast milk, will satisfy their hunger in less time 
than this. An infant may, however, nurse too quickly from the breast 
just as it may nurse too quickly from a bottle, and it is advisable, 
in such cases, to interrupt the nursing every two or three minutes for 
a period of one minute. 

As soon as the infant ceases to nurse, it should be removed from the 
breast, unless it is evident that it has taken only a small amount of 
milk — too small an amount properly to nourish it. In such cases, the 
nipple should be moved gently in the child's mouth, which may stimu- 
late it to nurse. The child should never, however, be allowed to lie 
with the nipple in its mouth, and not nursing, for more than one or 
two minutes. 

After removing the infant from the breast, the nipples should be 



BREAST-FEEDING 161 

cleansed with water or boracic acid solution. Alcohol and water, equal 
parts, may be applied if there is any tendency to inflammation; if 
any fissures are present, a 2 per cent, nitrate of silver solution should be 
painted over the cracks, and the baby should nurse through a nipple 
shield. 

If the breast becomes inflamed, nursing should be discontinued, and 
an ice-bag or a number of thicknesses of gauze wet in a saturated 
solution of magnesium sulphate should be applied over the inflamed 
surface. The breast should be w r ell bandaged, the mother kept at rest 
and given a laxative. If the breast becomes filled with milk, a sufficient 
amount may be pumped out to relieve the tension and pain. 

Human Milk. — Colostrum appears in the breasts at about the fourth 
month of pregnancy, and a few drops can usually be expressed from the 
breasts at this early period. The amount of colostrum gradually 
increases as pregnancy advances, and persists until the flow of milk is 
established, which usually occurs about three or four days after the 
baby is born. 

Colostrum is yellow in color due to the colostrum corpuscles, less 
sweet than human milk, more distinctly alkaline in reaction, and the 
specific gravity is higher — 1.036 to 1.040. It forms large coagula 
upon heating and may even coagulate upon standing. It contains 
a high percentage of protein and 3.34 per cent, of fat. The fat glob- 
ules vary in size, and colostrum corpuscles are present. 

These colostrum corpuscles consist of large cells filled with fat 
globules of varying size and containing a large nucleus, and are four 
or five times as large as the milk globules. 

The composition of colostrum, according to Camerer and Sdldner is: 

Water .* 86.70 

Proteids 3.07 

Fat 3.34 

Milk sugar 5 . 27 

Ash ' 0.40 

The colostrum corpuscles gradually disappear from the milk, and 
usually are not found after the twelfth or thirteenth day following 
lelivery. 

Advantages of Breast-feeding. — It is impossible to place too much 
emphasis upon the statement that breast milk is the best food for 
an infant. It is a well established fact that the milk of each mammal 
is especially adapted not only to supply the demands of nutrition for 
the growing body of its young, but also to develop the digestive 
apparatus. If, then, an infant is nursed 'by its mother, its digestive 
apparatus develops normally, and gradually builds itself up to the 
point where it can digest other foods than milk. 

Unfortunately, among the wealthier classes, many mothers are 
unable to nurse their babies for the entire period that is usually con- 
sidered advisable — ten or twelve months — and it is also not uncommon 
to find among the working class women who are so poor that they have 
11 



162 INFANT FEEDING 

to leave their babies at home or in a Day Nursery, and go out to work; 
or, but this is less common — those who are unable to nurse their babies 
because of poor food, overwork, and bad hygienic surroundings. 

However, the large majority of American women are between these 
two extremes, and many of them are able, and almost all of them can 
be persuaded to try, to nurse their babies. A very brief study of the 
chapter on Infant Mortality will show that almost all the deaths 
occur in bottle-fed babies. During the famous siege of Paris, the 
mortality among infants actually decreased because the women, in 
spite of all the privations and hardships which they were compelled 
to undergo, had to remain at home and nurse their babies. 

It is a mistake to wean an infant simply because it is not gaining in 
weight a sufficient number of ounces each week, or because it vomits 
occasionally, has abdominal pain, or the stools are not normal in color 
or consistency. It is possibly true that the breast milk this child is 
receiving is not an ideal food, but the correct treatment is not to wean 
the baby but to go carefully over all the facts connected with its 
feeding; see if the mother is worried by household or other cares, 
regulate her food, sleep and exercise; give her, if she requires them, 
appropriate tonics. 

Investigate the daily life of the infant with the same care — is it 
being fed regularly; are its bathing, clothing, sleep, and outdoor life all 
that is to be desired; can any medicine be given that might assist its 
digestion? Our efforts then would be directed not only to improving 
the quality and increasing the quantity of the milk by building up the 
mother, but also to place the child under those conditions which would 
tend to improve its digestion. 

If it still failed to gain and the quantity of the milk was deficient, 
a small supply of properly prepared cow's milk should be given after 
each breast-feeding. This method of giving after each breast-feeding 
just enough properly prepared cow's milk to compensate for the 
deficiency of the breast milk, is a plan that is applicable to a very 
large number of breast-fed infants. 

If the supply of breast milk, as is frequently the case, gradually 
becomes less, and it is found that at the proper hour for nursing the 
breast is practically empty, an entire bottle feeding may be given once 
or oftener during the day, and the number of partial breast feedings 
be reduced. It is, however, well recognized that the nursing of the 
infant tends to keep up the secretion of milk, and one is therefore 
reluctant to omit entirely any more breast feedings than are necessary. 

Many infants are weaned because a chemical analysis of the mother's 
milk shows that it does not conform to the accepted standard of breast 
milk. While there is a standard for breast milk, it is also true that 
this standard may vary normally between very wide limits, that 
different specimens taken from the same mother may also vary, and 
that the milk nursed by an infant may vary from the milk drawn from 
the same breast with a pump. 

It is also true that the analysis varies according to whether it is the 






BREAST-FEEDING 163 

fore, middle or end of a nursing. Moreover, it is expensive to have 
an analysis of breast milk made, and repeated analyses of the same 
milk may be necessary before its average composition is determined. 
While I am a firm believer in the necessity and importance of breast 
milk analysis, I still wish to enter a protest against weaning a baby 
simply because the analysis shows a milk that does not conform to 
the accepted standard. 

It is surely unwise to wean in such cases until every effort has been 
made to improve the quality and increase the quantity of the milk; 
we must remember that a poor breast milk is often better than a 
prepared bottle, and that breast milk contains substances that are of 
great importance to the infant, and of great protective value. 

There are rare cases when the breast milk should not be given, 
because, in spite of all that one can do, the baby does not gain in 
weight and does have constant indigestion; but in my experience, 
they are very rare indeed. 

It may well be asked "When and how should a baby be weaned?" 
Having decided to wean the baby, it is always safer to begin giving the 
cow's milk mixture much weaker than one would ordinarily employ 
in a healthy baby of the same age who had been fed continuously on 
the bottle. If the cow's milk mixture is started at about one-half the 
strength usually given to an infant of the age of the one being weaned, 
it may be gradually and cautiously increased if it is evident that the 
infant can digest it. 

If. an infant is doing w r ell on the breast, it is not wise to wean it 
during the hot summer months as the change from breast to bottle 
is quite liable to be associated with gastro-intestinal disturbances if 
the child is in a locality where the weather is very warm. Infants who 
are taken to a climate that is cool in summer would not come under 
this rule. 

It is safer to wean slowly than suddenly. At first one bottle-feed- 
ing each day may be given; if this agrees with the child, in two or 
three days a second bottle-feeding may be given. By this plan the 
breast-feeding may be gradually withdrawn and the bottle completely 
substituted. 

It is advisable to wean the baby if the mother has any disease which 
she may transmit to her child, such as tuberculosis or typhoid fever; 
or if the mother has any disease which the strain of nursing might 
aggravate, as acute pneumonia, tuberculosis or nephritis. Pregnancy 
in the nursing mother requires the weaning of the infant, and weaning 
may be done gradually if desired. If, however, the prepared milk 
given the baby does not cause any intestinal disturbance, no longer 
than one week should be consumed in the complete weaning. 

If the illness of the mother is of a minor character, and of such a 
nature that it will not be transmitted to the child, nursing at the breast 
may be continued for two or three feedings a day and a weak milk 
mixture given for the other feedings; but if the illness, while of a mild 
and transient character, is associated with severe symptoms, it is 



104 INFANT FEEDING 

often safer to discontinue nursing entirely for a few days, give the child 
a weak, modified milk mixture, and pump the breasts several times a 
day to retain the milk. Menstruation may cause temporary gastro- 
intestinal disturbance in the infant and perhaps make weaning neces- 
sary for several days. 

A wet-nurse who is syphilitic should not be allowed to nurse an 
infant, and an infant who has syphilis should not be allowed to nurse 
from a wet-nurse. In the first instance, the wet-nurse may infect the 
child, and in the second case, the child may infect the wet-nurse. If, 
however, an infant is suffering with inherited syphilis, it may, of 
course, be nursed by its own mother. 

Temporary weaning from one breast is necessary if the mother is 
suffering from a mastitis of that breast, and, if the inflammation has 
been severe, nursing must be resumed cautiously. 

Weaning depends, in the large majority of cases, upon the ability 
of the mother to nurse her baby. It is a mistake to keep an infant 
entirely on the breast, if the amount of milk secreted is insufficient for 
the nutritional demands of the infant. Many women of the higher 
classes are unable to nurse their infants entirely for more than a few 
months, and partial weaning, when the milk begins to fail, is necessary. 

Much can often be done to improve the quality and quantity of 
breast milk by building up the general health of the mother, giving 
her an abundance of milk, meat and eggs, with plenty of sleep and 
avoidance of all worry. 

In other cases, when the baby is doing fairly well, rather than make 
a change, nursing is prolonged until long after the infant is a year old. 
Almost all infants so fed become anemic, fail to develop normally, 
and rarely show a continuous and normal gain in weight. If a child 
is doing well on the breast, it is wise to begin giving it one bottle feeding 
a day when it is nine months old. The one bottle of prepared cow's 
milk is of advantage, in that it gradually trains the digestive organs 
of the infant to digest cow's milk; it also makes the weaning less 
abrupt. 

The amount of food being received by the infant at the breast is 
often a matter of importance as regards weaning, nutrition, and gastro- 
intestinal disorders. Assuming that an ounce of breast milk weighs 
one ounce, the infant may be weighed before and after feeding, and the 
difference in weight represents the number of ounces nursed. From a 
number of such records in my private practice, where the infants were 
in good health and gaining well, the following table is compiled: 

7 days old 10 to 16 ounces 

2 weeks old 14 to 20 " 

2 to 4 weeks old 18 to 24 " 

4 to 8 weeks old . 22 to 29 " 

2 to 3 months old 25 to 32 

3 to 4 months old 26 to 35 " 

4 to 6 months old 27 to 38 

6 to 9 months old 30 to 41 



BREAST-FEEDING 1 65 

These amounts represent, of course, only averages; the larger the 
child, the greater the gastric capacity and the more food it will require. 
The average composition of breast milk according to Rotch is: 

Woman's milk directly from 

the breast. Cow's milk freshly milkr-d. 

React ion Amphoteric (more alka- Amphoteric (more arid 

line than acid) than alkaline). 

Water 87 to 88 per cent. 86 to 87 per cent. 

Mineral matter . 0.2 per cent. 0.7 per cent. 

Total solids 12 to 13 per cent. 13 to 14 per cent. 

Fats 4 per cent, (relatively poor 4 per cent, (relatively rich 

in volatile glycerides) in volatile glycerides). 

Milk sugar .... 7 per cent. 4.75 per cent. 

Proteins 1.5 per cent. 3.5 per bent. 

Oaseinogen . . . \ to § of the total proteins 2.06" per cent. 

Whey proteins . \ to § of the total proteins 0.84 per cent. 

Coagulable proteins . . Small proportionately Large proportionately. 
Coagulation of proteins by 

acids and salts . . . W r ith greater difficulty; With less difficulty; curds 

curds small and floccu- large and tenacious. 

lent 
Coagulation of proteins by 

rennet Does not coagulate readily Coagulates readily. 

Action of gastric juice . Proteins precipitated but Proteins precipitated but 

easily dissolved in excess dissolved less readily. 

of the gastric juice 

The following table from Rotch shows the composition of normal, 
poor, over-rich and bad milk : 



Fat ... 

Sugar . 
Proteins . 
Mineral matter 


Normal milk 

(healthy life as 

to exercise ami 

food). 

4.00 

7.00 
1.50 
0.15 


Poor milk 

(starvation). 

1.10 
4.00 
2.50 
0.09 


Over-rich milk 

(rich feeding; 

lack of exercise). 

5.10 

7.50 
3.50 
0.20 


Bad milk 

(pregnancy. 
disease, etc.) 

0.80 
5.00 
4.50 
0.09 


Total solids . 
Water 


. 12.65 
. 87.35 


7.69 
92.31 


16.30 
83.70 


10.39 
89.61 



100.00 100.00 100.00 100.00 

Wet-nurse. — If a mother is unable to nurse her baby, and in those 
rather rare cases where she cannot be persuaded to nurse her infant, 
the employment of a wet nurse offers the best, simplest and safest 
method of feeding the baby. 

There are, however, certain objectionable features connected with 
wet-nursing that it is well to appreciate at the outset. The class of 
women who are usually available is generally undesirable. The baby 
is often illegitimate, and the nurse worried by her misfortune and 
annoyed by the father of her child and her so-called friends. The 
bringing of such an individual into a household is not usually desirable. 
A woman of a quiet and phlegmatic temperament is generally to be 
preferred, as nervousness and excitement on her part will often cause 
the breast milk temporarily to disagree with the infant. 



166 INFANT FEEDING 

It is not necessary that the age of the nurse's child should correspond 
to that of the child she intends to nurse. It is desirable that her 
baby be as young as possible if it is proposed to have her continue 
nursing for any considerable number of months. If her own child is 
seven months old or more, the probability of her being able to nurse 
for more than three or four months is not great. She should be between 
twenty and thirty years of age, and a chemical analysis of her milk 
is of advantage as a fair index of its quality. 

The only advantage in her being a multipara is that we have the 
history of a previous successful ability to nurse for a definite number of 
months. She should be free from syphilis and tuberculosis, have an 
even temper, and live as normal a life as possible as regards sleep, 
fresh air, and exercise. 

Her diet should consist of an abundance, but not an excess, of plain 
food, with a liberal supply of cow's milk, about one quart a day. 
She should avoid drinking much tea or coffee and all alcoholic 
drinks should be forbidden. A wet-nurse who must have ale or 
beer to stimulate her secretion of milk had better be dispensed 
with. 

The best test is to see and examine carefully her own baby. If it is 
strong, robust and well developed, one may be reasonably sure of her 
milk being of good quality and quantity. In Philadelphia, it is usually 
possible, by applying at several agencies, to secure almost immediately 
a wet-nurse with a negative Wassermann. 

In private practice among the class of patients who are capable of 
paying for the services of a wet-nurse, it is almost always possible to 
have one's directions, as to bottle feeding and general care and manage- 
ment of the infant, carried out in compliance with the orders of the 
attending physician. This is the reason why wet-nursing has never 
been popular in the United States; still, there are a certain number of 
infants who, as a result of malnutrition or disease, will usually do better 
on wet-nursing than on the bottle. 

Among this class may be mentioned especially premature or delicate 
infants. It is of great help in such cases to be able to secure for them a 
plentiful supply of good breast milk. Young infants, convalescing 
from an acute illness, especially of the gastro-intestinal tract, usually 
do well if given to a wet-nurse; or a young infant who has been badly 
fed; and has failed to gain in weight for some weeks, will usually gain 
rapidly if given a sufficient supply of breast milk. In Philadelphia 
I have seen the mortality in a certain foundling asylum very greatly 
reduced by boarding out the infants to women who would partly 
breast-feed and partly bottle-feed them. The feeding and care the 
infant receives is watched systematically by a competent social 
worker, and a member of a board of women managers. 

Alexins. — There are present in human milk substances called alexins, 
which possess bactericidal and globulicidal properties. They are 
probably partly formed in the breasts and partly derived from the 
blood. They, undoubtedly, tend to partially protect the breast-fed 









PE R( 'EN TA GE FEEDING 1 07 

infant from infection of the gastro-intestinal tract. Breast milk also 
contains other protective substances agglutinins and antitoxins —and 
still other antibodies, if the mother is immune, may he present in 
her milk. 

PERCENTAGE FEEDING. 

The most satisfactory and accurate way of determining the com- 
position of the infant's food is to mix it according to percentages. 
It is not, however, a method of feeding, nor does it determine the 
ingredients or the amount of the various food elements which are 
suitable in the individual case. These factors depend upon the age, 
size, and health of the infant, and upon the digestive ability of its 
gastro-intestinal tract. 

The problem is how to change or modify the percentages of cow's 
milk so as to make it resemble human milk. The first question which 
naturally suggests itself is, why one should feed a baby on different 
percentages at different ages when the percentages of breast milk 
do not change to any appreciable degree during the entire period of 
breast feeding. 

The answer is that each mammal furnishes a milk that i> especially 
adapted to the growth and development of the digestive organs and 
body of its young. The milk of the cow is therefore adapted to 
the growth and development of the digestive organs and body of the 
calf, and is not adapted to the infant. 

The young infant can digest cow's milk only in weak mixtures, 
and as it grows older and stronger can digest larger quantities and 
stronger mixtures. Cow's milk can never be transformed into human 
milk; but we can modify it so as to make it possible for an infant to 
live and grow and develop upon it. 

Percentage feeding offers a method of calculating in ounces and 
drams the composition of a given formula when that formula is written 
in percentages; or, if written in ounces and drams, one can easily 
calculate the percentage of fat, proteins, and sugar that it contains. 

The accuracy of such a mixture, however, depends primarily upon 
the constant composition of the milk and cream used. In the labora- 
tory there is very little variation in the composition of such a formula ; 
but, in the home, modification of the milk is necessarily not so accu- 
rate. The errors which occur, however, are in the actual percentages, 
the proportions of the various food elements being little altered, con- 
sequently most infants are able to compensate for these errors, and the 
slight variations in the composition of the food are not noticeable. 
Fats, carbohydrates, and proteins are the elements that especially 
concern us in the modification of cow's milk, the salts being of less 
practical importance, hence the percentage formula states only what 
percentage of these three elements should be used. 

Modification of Milk. — Modifying milk is the process of diluting it 
and adding to it in such manner that the fats, proteins, and carbo- 



168 INFANT FEEDING 

hydrates are combined in the proper proportions to make them 
assimilable and properly to nourish the child. Because of the difference 
in the composition of cow's milk and human milk, modification is 
always necessary when cow's milk is fed to the young infant; for, 
while the percentage of fat is nearly the same, the percentage of sugar 
is lower in cow's milk, and the percentage of proteins higher. 

The old method of infant feeding, which was simple dilution while 
decreasing the amount of proteins to normal, caused such a decrease 
in the amount of fat and carbohydrates that it did not meet the 
indications of modified milk. In order to make the mixture prepared 
from cow's milk correspond to the general relation of fat, sugar, and 
proteins in human milk, it is necessary to use cream in the feeding 
mixture so that the dilution which reduces the amount of proteins 
will not cause too great a diminution in the amount of fats; for when 
cream forms there is an unequal division of fats in the upper and lower 
contents of a receptacle, but the proportion of sugar and proteins is 
practically equal. Thus, simply stated, the modification of milk 
consists in the dilution of cream with water and the addition of milk 
sugar. 

The protein in cow's milk is 4 per cent. ; in human milk 1J per cent.; 
and to reduce the 4 per cent, in cow's milk to the required percentage 
in human milk, it is necessary to add a diluent, and the one commonly 
used is water. This addition of water, however, also reduces the 
percentage of fat; in fact, usually reduces it to a point lower than the 
percentage desired in the modified milk mixture. Now, to increase this 
percentage of fat it is necessary to add to our mixture something that 
contains a relatively high percentage of fat and a low percentage of 
protein, therefore we add cream. Cream, containing as it does a 
high percentage of fat, can easily be reduced by the addition of water 
so as to contain any desired percentage. But, as this addition of water 
also reduces the percentage of protein in the cream, it is often necessary 
to add to the mixture an ingredient that contains a low percentage of 
fat and a high percentage of protein. This is^well supplied by fat- 
free milk, which contains 4 per cent, of protein and practically no fat. 
Cow's milk contains 4 per cent, of milk sugar, human milk 7 per cent., 
and our addition of water still further reduces the sugar percentage. 
To bring the sugar percentage in our modified milk up to the desired 
amount, we simply add milk sugar. The modification of milk is thus 
briefly as follows: 

We add water to cow's milk to dilute its 4 per cent, of protein; we 
add cream which is rich in fat to bring up the fat to the percentage 
desired; and we add milk sugar to raise the percentage of sugar to 
that required by the infant, usually 6 or 7 per cent. Modified milk 
mixtures may be made with cream, whole milk, water, and milk sugar; 
or, instead of the whole milk, fat-free milk may be used. The latter 
method is, I believe, the better for home modification, therefore, will 
be the one followed. It is easy to understand, and the modifications 
are quickly made at home. 



PERCENTAGE FEEDING 169 

In order that the modification of milk at home may, as nearly as 
possible, approach the exactness of the laboratory, it is necessary that 
the family be supplied with milk and cream of definite percentages. 
This milk or cream may be procured in Philadelphia from those dairies 
recommended by the Milk Commission of the Philadelphia Pediatric 
Society. All bottles and nipples should be carefully sterilized. The 
arms and forearms of the person selected as modifier should be 
thoroughly cleansed and she should have the following for her modi- 
fications: milk and cream of known percentages, sterile water, lime- 
water, milk sugar, a cream dipper, milk sugar measures holding 3f 
drams, an 8 ounce graduate, a large spoon sterilized. Gravity cream is 
often used, and can be obtained as follows: if the milk is allowed to 
stand in the ordinary quart jar for eight hours, the top 4 ounces' 
represent a 20 per cent, fat cream, the top 6 ounces a Hi per cent, fat 
cream, and the top 8 ounces, a 12 per cent, fat cream. Gravity cream 
contains more bacteria than does separator cream, but the centrifuge, 
it is claimed by some, does injury to the emulsion of the fat. Personally, 
I have obtained equally good results from both creams. 

It must be remembered that accuracy is the keynote to a home 
modification, and it is best that all directions to the mother or nurse 
be carefully written out in ounces of cream, milk, water, lime-water, 
and measures of sugar of milk. The physician should learn to think 
in percentages, and, having decided upon the percentages to be used, 
be guided by the child's age, development, weight, digestion, and, 
if indigestion be present, also influenced by the fact whether it is the 
fat, protein, or sugar which is the cause of the indigestion. After taking 
these factors into consideration, he should decide upon the exact per- 
centage of fat, sugar and protein to be used, and, by reference to his 
pocket memoranda, transfer this into ounces for the benefit of the 
mother or nurse. 

A convenient and easily understood form of home modification 
is as follows: from a quart of milk, which has been bottled eight hours, 
remove the top 8 ounces; count this as 12 per cent, fat cream. Count 
as fat-free milk, the lowest 8 ounces of the quart. Using this 12 per 
cent, fat cream and the fat -free milk, the following percentages can be 
obtained, covering fairly well the different combinations of fat, pro- 
tein and sugar desired. One quart of milk is enough by this method 
until the baby is about three months old. 



FIRST WEEK. 

Fat 2.00 

Sugar , 5.00 

Proteins 0.75 

12 per cent, cream. Fat-free milk. 

Cream 33^ ounces 

Milk \y% ounces 

Lime-water, 1 ounce 

Water q. s. 20 ounces 

Milk sugar 2 measures 



170 INFANT FEEDING 

SECOND WEEK. 

Eat 2.00 

Sugar 6.00 

Protein 1.00 

Cream 334 ounces 

Milk 2}/2 ounces 

Lime-water 1 ounce 

Water q. s. 20 ounces 

Milk sugar 2^ measures 

THIRD WEEK. 
Fat 2.50 

Sugar 6.00 

Proteins 1.00 

Cream 434 ounces 

Milk \ z /i ounces 

Lime-water . 1 ounce 

AVater q. s. 20 ounces 

Milk sugar 2^ measures 

FOUR TO SIX WEEKS. 

Fat 3.00 

Sugar 6.50 

Proteins 1.50 

Cream 5 ounces 

Milk 3^ ounces 

Lime-water 1 ounce 

Water q. s. 20 ounces 

Milk sugar 2}/i measures 

SIX TO TWELVE WEEKS. 

Fat 3.50 

Sugar 6.50 

Proteins 1.50 

Cream &% ounces 

Milk 314 ounces 

Lime-water 1 ounce 

Water . q. s. 20 ounces 

Milk sugar 2 34 measures 

THREE TO FOUR MONTHS. 

Fat 4.00 

Sugar 7.00 

Proteins . . 1.50 

Cream • 6% ounces 

Milk 234 ounces 

Lime-water 1 ounce 

Water q. s. 20 ounces 

Milk sugar 2 x /2 measures 

FOUR TO EIGHT MONTHS. 

Fat : 4.00 

Sugar 7.00 

Proteins 2.00 

Cream 6% ounces 

Milk 4% ounces 

Lime-water 1 ounce 

Water q. &. 20 ounces 

Milk sugar 234 measures 

EIGHT TO NINE MONTHS. 

Fat 4.00 

Sugar 7.00 

Proteins 2.50 

Cream Q' 6 /i ounces 

Milk 73^ ounces 

Lime-water 1 ounce 

Water . q. s. 20 ounces 

Milk sugar 2 measures 



PERCEXTACE FEEDING 



171 



NINE TO TEN MONTHS. 

I ,n 1. 00 

Sugar 7.00 

Proteins 3.00 

Cream 6*4 ounces 

Milk 10^2 ounces 

Lime-water 1 ounce 

Water q. s. 20 ounces 

Milk sugar \y 2 measures 

TEX TO TWELVE MONTHS. 

Fat 4.00 

Sugar 5.00 

Proteins 3.50 

Cream 6*4 ounces 

Milk 11*4 ounces 

Lime-water 1 ounce 

Water q. s. 20 ounces 

Milk sugar Yi measure 

AFTER TWELVE MONTHS 
Unmodified cow's milk. 

In order to obtain certain low protein percentages with certain fat 
percentages, it is necessary, instead of removing the top eight ounces 
and using a 12 per cent, fat cream, to remove the top six ounces for a 
16 per cent, fat cream, or the top four ounces for a 20 per cent, fat 
cream. The following table designed by Dr. Maynard Ladd, makes 
this a calculation of a few moments only. 





20-ounce mixtures. 
Percentage of 




Ounces of cream 


Ounces fat-free milk -j. 
used with creams of i 


r. 
7 














. 


«i 


*j 




■~ 


= 












a 


= = = 


= 


= 


~ 


- .5 




No. 






B 


oa 


- 


III 


- 


z. 


■~ 


/. 


tt 




























^ 


a 




<A 


ft 


X a c 

» - la 


ft 


ft 


a 


a 5 


= 




fa 


X 


- 


< 


~ 


N 


- 


- 


- 


fi 3 


2 


1 


1.50 


4.50 


0.25 


5 




. m 










2 


2 


! 1.50 


4.50 


0.50 


5 


3 


24 


2 iy 2 




H 


1 


14 1 


2 


3 


2.00 


5.00 


0.25 


5 






.. 2 










24 


4 


2.00 


5.00 


0.50 


5 




Wa 


21, 2 






4 


1 1 


24 


5 


2.00 


5.00 


0.75 


5 


4 


34 


2*2 2 


4 


14 


2*4 


24 1 


2 


6 


2.00 


5.50 


1.00 


5 


4 


*% 


2V 2 2 


14 


2K2 


34 


3M 1 


24 


7 


2.50 


5.00 


0.50 


5 






34 2V 2 








M 1 


24 


8 


2.50 


5.50 


0.75 


5 




4*4 


34 21. 2 




4 


14 


2 1 


24 


9 


2.50 


6.00 


1.00 


5 


5 


414 


34 21, 


1 


14 


2 3 4 


24 1 


242 


10 


3.00 


6.00 


0.50 


5 






3M 3 








*4 1 


242 


11 


3.00 


6.00 


0.75 


5 




5 


3*4 3 






14 


2 1 


242 


12 


3.00 


6.00 


1.00 


5 


6 


5 


3*4 3 




1 


2H 


3 1 


24 


13 


3.00 


6.00 


1.25 


5 


6 


5 


3% 3 


14 


24 


sy?. 


44 1 


24 


14 


3.00 


6.50 


1.50 


5 


6 


5 


3*4 3 


24 


sy 2 


4*4 


54> 1 


24 


15 


3.00 


6.50 


2.00 


5 


6 


5 


3*4 3 


5^ 


642 


7% 


83^ 1 





16 


3.50 


6.00 


0.50 


5 




• ■ 










242 


17 


3.50 


6.00 


0.75 


5 






4^ 3V 2 








1 1 


242 


18 


3.50 


6.50 


1.00 


5 




5*4 


4M 3^ 






14 


24 1 


242 


19 


3.50 


6.50 


1.25 


5 


7 


5*4 


±y 2 sy 2 


y?. 


iM 


3 


4 1 


242 


20 


3.50 


6.50 


1.50 


5 


7 


5% 


4y 2 sy 2 


2 


34 


44 


542 1 


24 


21 


4.00 


6.00 


0.60 


5 






. . 4 










242 


22 


4.00 


6.00 


0.75 


5 






5 4 








1 1 


2 l / 2 


23 


! 4.00 


7.00 


1.00 


5 






5 4 






1 


2 1 


2*4 


24 


: 4.00 


7.00 


1.25 


5 




6*4 


5 4 




3 4 


24 


34 1 


2y 2 


25 


4.00 


7.00 


1.50 


5 


8 


6*4 


5 4 


1 


214 


4 


5 1 


242 


26 


4.00 


7.00 


2.00 


5 


8 


6*4 


5 4 


3*4 


4*4 


6H 


7^ 1 


24 


27 


4.00 


7.00 


2.50 


5 


8 


6*4 


5 4 


6*4 


742 


94 


104 1 


2 


28 


4.00 


7.00 


3.00 


5 


8 


6*4 


5 4 


94 


104 


124 


13M 1 


i4 2 


29 


4.00 


6.00 


3.00 


5 


8 


6*4 


5 4 


914 


1014 


124 


134 1 


1 


30 


4.00 


5.50 


3.00 


5 


8 


6:4 


5 4 


94 


ioy 2 


124 


134 1 


4 



172 INFANT FEEDING 

This, however, will only result in making the percentages of the 
different food elements the same as in human milk; for, no matter 
how cow's milk is modified, it will still differ from human milk because 
the composition of the fat is different, the ferments are not the same, 
and the specific serum reaction remains unchanged. 

The method devised by Rotch is, perhaps, the most popular one for 
infant feeding. It is based upon the principle that we cannot feed all 
infants on the same mixture, and that each infant should be considered 
as a distinct problem in constructing a formula. The mixtures are 
made from cream, skimmed milk, milk sugar, and lime-water, and the 
diluent generally used is water. The constituents of the milk can be 
rearranged by this method so that any desired formula can be produced, 
and such mixtures are usually prescribed in percentage form; that is, 
fats, 2.5 per cent. ; carbohydrates, 5 per cent. ; proteins, 0.75 per cent. 

If a given formula does not agree with an infant, it is easy to reduce 
or increase any of the food elements by decreasing or increasing the 
percentages in the mixture. The best method is for the physician to 
think in percentages. After deciding just what percentage of fats, 
protein, and sugar the infant or child may require, he should write a 
prescription for these percentages, the number of feedings necessary 
in twenty-four hours, the amount in ounces and drams of each feeding, 
the degree of alkalinity, and the degree of heating which the feedings 
may require. This is sent to a laboratory, and each day the bottles 
of milk are prepared according to his prescription, and are left packed 
in ice at the home of the patient. 

If a milk laboratory is not located near the residence of the child, 
or if the expense of laboratory feeding is too great, the milk may be 
modified at home. This home modification is not difficult. The phy- 
sician must w r rite out his directions carefully and in detail, and any 
one of ordinary intelligence is capable of carrying them out. In fact, 
home modification has practically largely displaced laboratory feeding. 
A family that can afford to feed a child by the laboratory method 
usually has a child's nurse who is quite competent to do home modifi- 
cation. 

Calculation of Percentages. — Given a milk or cream containing a 
standard amount of the various food elements, the calculation of a 
percentage formula is easily made by employing the following method : 

Percentage desired X quantity desired 
Divided by the standard per cent. 

By means of this formula the amount of fat and proteins is deter- 
mined; for example, 20 ounces of a 3 per cent, fat and 2 per cent, 
protein mixture is desired, for which a 12 per cent, fat cream is used. 
In order to determine the proper amount of this 12 per cent, cream 
to use, the desired percentage (3) is multiplied by the desired number 
of ounces (20) and divided by the standard percentage (12) which 
gives us 5 ounces of cream. 

Standard per cent. 3 X desired quantity 20 

_ = 5 

Standard per cent. 12 



PERCENTAGE FEEDING 173 

In order to determine the proper amount of milk or eream which this 
20-ounce mixture must contain to give it a 2 per cent, protein content, 
the desired percentage (2) must be multiplied by the number of ounces 
desired (20), and this divided by the standard percentage (3^), which 
gives approximately 11 J ounces as the result. 

Inasmuch as the cream added to give the desired percentage of 
fat to the mixture does not contain enough proteins to furnish the 
desired percentage of proteins, the difference is made up by adding 
skimmed milk which raises the protein content without influencing 
the fat content. This particular formula requires only 5 ounces of 
cream to furnish the necessary percentage of fats, whereas 11^ ounces 
of milk or cream are necessary to provide the proper amount of pro- 
teins; therefore, the difference between 5 ounces and 11^ ounces, or 
6J ounces, of fat-free milk must be added. 

The amount of sugar in percentage formulas is determined by 
estimating the amount of sugar needed in the mixture, subtracting 
the amount of sugar in the milk and cream utilized to supply the 
desired amount of fats and proteins for that particular mixture, and 
supplying the difference by adding milk sugar. Thus, if 6 per cent. 
carbohydrates is desired in the above formula, 6 per cent, of 20 ounces, 
or 1.2 ounces, will be required. 

Five ounces of cream are used to furnish the fats and proteins, and 
this contains 4 per cent, carbohydrates or 0.2 ounce; therefore 0.2 
ounce, or the amount of carbohydrates already contained in the 
formula, is subtracted from 1.2 ounces, the total amount of carbo- 
hydrates required, leaving 1 ounce of carbohydrates to be supplied. 

Five per cent, of lime water is usually added to these mixtures, and 
then enough of boiled water to make 20 ounces. This formula would 
read as follows: 

]$ — 12 per cent, fat cream 5 ounces 

Fat-free milk none 

Sugar of milk 1 ounce 

Lime-water 1 " 

Boiled water q. s. ad. 20 ounces 

Amount of Cream in Milk. — Cream is technically any milk which 
contains over 4 per cent, of fat. When milk is allowed to stand, the 
cream which forms at the top of the receptacle varies in its fat content, 
that at the top being much richer, and the cream below it thinner at 
different depths, until skimmed milk or fat-free milk is reached. The 
following diagram shows approximately the percentages of cream to 
be found at different levels in a quart bottle of a 4 per cent, fat milk 
which has been allowed to stand for six to twelve hours (Fig. 25). 

Albumin Milk: Eiweissmilch : Protein Milk. — Albumin milk is a 
preparation containing a high percentage of protein (3 per cent.), 
very little sugar (1.5 per cent.), and 2.5 per cent, of fat. It has been 
developed on the theory that sugar is the main cause of intestinal 
fermentation, and that fermentation of the sugar depends on the 



174 



INFANT FEEDING 




f " 5 " V 


" 6 " 


"8" 


" 10" 


" 16 " 


" 20 " 


" 24 " 


32 ounces 



22 f f 



20^ 



6$ 



concentration of the whey and the relative proportions of casein and 
sugar in the mixtures. A diminution of the salts is effected by dilution 
of the whey. 

Albumin milk is claimed by Finkelstein and Meyer to be beneficial 
in all disturbances of nutrition which are accompanied by diarrhea, 

and may also be given to the well infant 
from birth. Albumin milk is prepared by 
heating one quart of whole milk to 100° 
F., and adding 4 teaspoonfuls of essence 
of pepsin, which is thoroughly stirred in, 
and the mixture is then allowed to stand 
at 100° F. until a curd has formed. The 
whey is then separated from the curd by 
straining through a linen cloth, and is dis- 
carded, and the curd is pressed through a 
fine sieve two or three times by means of a 
wooden mallet or spoon, one pint of water 
being added during this process. 

The precipitate should now be very finely 
divided, and the mixture should look like 
milk. One pint of buttermilk is now added. 
Buttermilk contains very little sugar of 
milk, and its lactic acid content is of benefit. 
One quart of albumin milk contains about 
380 calories, so that it is necessary to increase 
the caloric value of this food by giving 
some additional nourishment as soon as 
improvement is noted. 
It can readily be seen that the preparation of albumin milk may 
prove quite a difficult task in the home, and this to a great extent 
limits its general application. But the principles of albumin milk 
feeding .may be carried out in the home by the addition of powdered 
casein and paracasein to ordinary milk mixtures. 

Buttermilk. — Buttermilk has long been used in the feeding of 
infants, and good results are usually obtained, because it contains a low 
percentage of sugar, 3 to 4 per cent., a low fat content, J to 1 per cent., 
and a high protein content, 2 to 3 per cent.; this is the old-fashioned 
buttermilk which was made from sweet milk as a by-product in the 
manufacture of butter. 

It can be made at home by thoroughly mixing a quart of fresh 
milk, a pint of water, a pinch of salt, and one lactic acid bacilli tablet, 
and allowing this mixture to stand in a covered receptacle at room 
temperature for from eighteen to twenty-four hours, when it may be 
placed on ice until used. But since it can be procured from any milk 
dealer, it is needless to make it at home except in localities where 
it is unobtainable. 

Buttermilk contains from 0.5 to 0.7 per cent, of lactic acid, and the 
lactic acid bacilli are alive and active in it, unless they have been 



Fig. 24. 



PERCENTAGE FEE DISC 175 

destroyed by heating. It contains more whey protein than fresh milk, 
and the casein it contains is very finely divided, so that it is most 
advantageous in those cases which require a low fat and high protein 
content in easily assimilable form. 

Buttermilk is very rarely given plain, however, but is usually mixed 
with wheat flour and cane sugar. To each quart of buttermilk two 
tablespoonfuls of cane sugar and a tablespoonful of wheat flour are 
added, and this mixture is boiled for two or three minutes w r hile con- 
stantly stirred, after which the desired feedings are bottled and placed 
on ice until needed for use. 

The action of the lactic acid bacilli is, of course, lost in this mixture, 
since these organisms are killed by the boiling. 

Commercial buttermilk is now made on a large scale, and is a stabile 
product. Much time and thought have been devoted to its production, 
and, as made by the Abbott Dairy, of Philadelphia, it is a product 
w T hich has a constant food value, and can be used with confidence in 
those cases where buttermilk is indicated. Their process is as follows: 

From the best whole milk, 2 per cent, of the fat is removed, leaving 
a milk that contains fat 2 per cent., sugar 4 per cent., protein 3.5 to 
4 per cent. This milk is heated to 180° F., and kept at this temperature 
for thirty minutes. The milk is then rapidly cooled, and when it has 
been reduced to 76° F. a starter is added, and during the following 
twelve hours the milk is kept, as nearly as possible, at 75° to 76° F. 
It is then churned for thirty minutes, being cooled during the process 
of churning. The milk is now bottled, the temperature of the milk 
when bottled being reduced to 34° F. It is then placed in the 
refrigerator and sold to the consumer the next day. 

The starter is made by adding lactic acid and Bulgarian bacilli to 
sterilized skimmed milk. The total solids of this buttermilk are 10 
per cent., containing 2 per cent, fat, 4.25 per cent, sugar, 3 per cent, 
protein, and 0.75 per cent, of lactic acid. 

Whey.— Whey is an opalescent liquid which remains after the 
coagulation of casein. Its composition is as follows : 

Protein 0.8 per cent. 

Fat 0.2 

Sugar 4.7 " 

Lactic acid 0.3 " 

Salts 0.6 

The solid portion of the whey of cow's milk is composed of lact- 
albumin, lactprotein, and extractives. Whey is made by adding two 
teaspoonfuls of essence of pepsin or liquid rennet to a pint of luke- 
warm skimmed milk, and stirring it just enough to mix it thoroughly. 
It is then allowed to stand until the milk separates into a solid and 
liquid portion, when the curd is broken up, and the whole preparation 
is strained through several thicknesses of cheesecloth. The whey 
passes through the cloth, but it contains the rennin of the rennet so 
that, before it can be mixed with skimmed milk, whole milk, or cream, 
the rennin must be destroyed by heating the whey to 150° F., and then 
allowing it to cool, 



170 INFANT FEEDING 

Whey is given to infants either combined with a cream mixture or 
alone. When combined with certain percentages of cream, we have a 
mixture in which the proteins are largely lactalbumin and lactoglobulin, 
thus resembling the protein content of human milk. Whey, alone, is 
an excellent preparation for infants suffering with gastro-intestinal 
disturbances when it is desirable to suspend milk temporarily; it is' 
used quite often in infant feeding. 

Proprietary Foods. — Patent, or proprietary, infant foods may be 
divided into milk modifiers and milk foods, those in the first group 
being used in combination with milk, those of the second being intended 
as a perfect food which does not require the addition of anything but 
water. These foods may be subdivided according to their ingredients 
as follows: 

1. Dried milk, to which completely malted cereals have been added. 
Horlick's Malted Milk and Allenbury's Food are examples of this 
group. 

2. Dried milk in combination with partially malted cereals, as 
combined in Xestle's Food and Carnrick's Food. 

3. Completely malted cereals which contain the carbohydrates in 
soluble form and w T hich are practically a desiccated malted extract. 
They contain a very small amount of protein. Mellin's Food is a 
good example of this class. 

4. Partially malted cereals, such as Benger's Food, which contains 
a pancreatic ferment that causes the conversion of starch; and Allen- 
bury's Food, No. 3, Moore's Food, and the Savory Foods. Certain 
preparations in this class f such as Loeflund's Malt Soup, are not only 
digestible, but when combined with cow's milk may prove quite 
nourishing for a limited time. 

5. This group includes the cereal foods in which there has been 
little or no conversion of starch, and includes Robinson's Patent 
Barley, Ridge's Food, Neave's Food, and Imperial Granum. 

The following table, furnished by Morse and Talbot, shows the 
composition of the most widely known infant foods on the market: 

Fat. Sugar. Protein. Starch. Ash. 

Condensed milk: 

Eagle Brand . . 9.61 

St. Charles Brand 8 . 70 
Ramogen . . .16.50 

Mammala . . . .12.12 
Horlick's Malted Milk 8.78 
Mellin's Food . . . 0.16 
Mead's Dextro-Maltose . . 
Laibose .'. 17.00 

, Allenbury's Food No. 1 18 . 60 
Allenbury's Food No. 2 15 . 88 
Allenbury's Food No. 3 1 . 05 
Eskay's Albuminized 

Food . . . .3.52 
Nestle's Food . 5.50 

Ridge's Food . . . 0.26 
Benger's Food . . 0.92 
Imperial Granum . 1.04 

Wheat Flour . . . 1.00 



54.94 


8.01 






1.78 


10.95 


8.80 






1.40 


34.65 


7.00 






1.50 


55.34 


24.35 






4.93 


67.95 


16.35 






3.86 


79.57 


10.35 






4.30 


93.00 








2.00 


55.00 


18.00 






4.00 


66.55 


10.66 






3.95 


70.90 


9.90 






3.71 


25.11 


10.23 


60.01 


0.60 


55.82 


6.70 


29.90 


0.99 


58.93 


14.34 


15.39 


2.03 


7.80 


12.50 


73.67 


0.61 


3.34 


12.12 


77.02 


0.97 


1.80 


14.00 


73.54 


0.39 




11.40 


76 


10 


0.50 



PROPRIETARY FOODS 177 

It is readily apparent from the preceding analysis of these foods that 
no individual preparation contains the proper amount or proportion 
of food elements to sustain the life of an infant and provide for its 
growth for any great length of time. Most of them show a deficiency 
in fats and an excess of carbohydrates which prohibit their continued 
use, inasmuch as the proportion of fat in an infant's food is a most 
important consideration. 

The proteins in these preparations are either heated and dried 
proteins of cow's milk, which are most indigestible, or vegetable pro- 
teins which are unsuitable for the infant. It is not uncommon to hear 
of infants who have apparently thriven on one particular food; but 
these cases do not prove that patent foods are better than modified 
milk; on the contrary, they should be regarded as occasional instances 
in which the particular food given has fortunately contained the 
various food elements in proper proportion and combination for the 
individual case. 

The milk modifiers, such as Eskay's Food, are, perhaps, least 
objectionable, since they provide starch in a form easy of digestion, 
and the food is added to fresh cow's milk. 

Patent foods are used principally by the careful practitioner at the 
weaning period; when there is milk idiosyncrasy; or as a substitute for 
milk during an acute illness; but their routine use in infant feeding is 
to be condemned, not only on account of the faulty composition of 
these preparations, but because of the careless prescribing it leads to 
in treating infants. Another great objection is the cost of the food. 
which far exceeds that of modified milk. 

Meat Preparations. — Meat preparations have no place in the feed- 
ing of a normal infant, but they are important additions to the diet 
of the sick child when cow's milk must be temporarily withdrawn. 
Raw meat juice is the most popular preparation, and is made by 
adding an equal quantity of cold water to finely ground raw beef, 
and allowing it to stand for half an hour, after which the juice is 
squeezed out through muslin. 

Meat juice, thus made, contains approximately 5 per cent, proteins, 
3 per cent, extractive matter, and 0.7 per cent, salts, and may be given 
alone or combined with whey, cream, barley-water, or even with 
Mellin's or some other prepared food. Meat juice is especially valuable 
in the treatment of scurvy, since it possesses distinct antiscorbutic 
properties. 

Proprietary meat preparations occasionally give good results, but 
are not nearly as suitable for the infant as the fresh juice, and have no 
antiscorbutic effect. 

Meat broths, made from mutton, beef, and veal, also chicken broth, 
are all useful when milk feedings are temporarily contraindicated on 
account of gastro-intestinal disturbances. Several prepared beef 
juices are on the market, the most popular of which are Valentine's, 
Brand's, Armour's, YYyeth's and Burgoynes's, also the preparations 
known as Puro and Bovinine. 
12 



178 INFANT FEEDING 

Malt Soup. — Malt soup is a proprietary food containing wheat flour, 
malt, and milk, upon which an infant can be fed for several months 
if the child's stomach tolerates it. It is indicated particularly in rachitis 
and in dyspeptic infants who have suffered greatly from malnutrition. 

To make malt soup, 4 ounces of wheat flour should be mixed 
thoroughly with a quart of milk, and strained through gauze. To this 
is added a quart of warm water containing 6 ounces of thick malt 
and 30 grains of potassium carbonate in solution. For young infants 
one-half of this quantity can be made up, and more water and less 
milk may be used. As the infant grows older, and the gastro-intestinal 
tract becomes stronger, more milk should be added to the soup, 
but the amount of wheat and flour need not be changed. 

ARTIFICIAL FEEDING. 

Artificial infant feeding is the substitution of any other form of 
nourishment for breast milk, which is the normal food of infants. 
There are but few food elements, however, and the baby's food must 
contain some of them, perhaps all of them, but should not contain 
any other elements. These food elements are fats, carbohydrates, 
proteins, and salts, and they must be given in correct quantity and 
proportion. The infant must also be given sufficient food to make 
it thrive and gain weight, and this amount can be determined by 
calculating the caloric value of the food given. 

Since the milk from the mother's breast for a period of twelve to 
fourteen months shows no variation in composition, it would seem as 
though the artificial food substituted for breast milk should be made to 
resemble human milk in composition, and that it would need but 
little change; but this is not the case, for no food has been discovered 
which is even approximately a substitute for breast milk. 

A modification of cow's milk that will make its composition resemble 
human milk is the most satisfactory substitute yet discovered, although 
it is neither as nutritious nor digestible as human milk, is not sterile, 
and contains none of the biological constituents. Mare's milk resembles 
human milk more closely than does cow's milk; but it is rarely used 
because of the difficulty in obtaining it. Goat's milk bears a slightly 
closer resemblance to human milk than does cow's milk, but this, 
too, is rather difficult to obtain, and must also be modified, therefore 
its use in infant feeding is not popular. 

Modified cow's milk is consequently the best practicable substitute 
for human milk. Proprietary foods and condensed milk are rarely 
used by the physician for any considerable time, while other prepara- 
tions, such as dextrinized gruels, malt soup, albumin-water, meat 
preparations, albumin milk, barley-water, and rice-water are used 
principally as substitutes when milk is temporarily suspended in the 
course of diseases of the gastro-intestinal tract. 

Variety of Fats, Carbohydrates, and Proteins. — Fats. — The character 
of the fats in a feeding mixture can not be changed, but the emulsion 



CALORIC FEEDING 179 

can be made more complete by homogenization, which reduces the 

fat droplets to a very small size. Olive oil, which is another form of 
fat, may be introduced into the infant's food by homogenization. 

Carbohydrates. — Milk Sugar. — Lactose is the most suitable form of 
sugar to insure the growth of the infant, because it is more completely 
absorbed than other disaccharides, and it favors the growth of the 
normal intestinal flora, thus aiding digestion. Moreover, few of the 
other organisms in the intestinal tract thrive upon it, so that to 
a certain degree it protects the tract from the development of 
undesirable bacteria. 

Maltose is too expensive to be used alone in infant feeding, and is 
usually combined with dextrines. On ingestion it is immediately 
split up into dextrose, and has. therefore, more of a laxative effect 
than the dextrines, and is less favorable to the growth of normal 
intestinal flora. Dextrin-maltose is valuable in cases where intestinal 
disturbances are due to fermentation of milk sugar. 

Cane Sugar. — This is the least desirable of the various sugars because 
it undergoes alcoholic fermentation instead of lactic acid fermentation, 
and does not promote the growth of normal intestinal flora. There 
are no indications for using cane sugar in infant feeding. 

Starch. — Starch should not be given to infants under four months 
of age, and it is inadvisable to allow any large quantity of starchy 
food until after the first year. On the other hand, some starch should 
be included in the food after the sixth month, but must be given in 
definite amounts, the same as fats and proteins. Starch is especially 
indicated in cases of sugar fermentation and intolerance to sugar. 
It is usually given as a cereal cooked in water, such as oatmeal, or as 
rice-water, or barley-water, or in the form of gruel. An excessive 
amount of starch may cause constipation and marked disturbance of 
digestion and nutrition. 

Proteins. — The protein of cow's milk is less easy of digestion than 
that of human milk on account of the greater amount of casein which 
it contains, resulting in the formation of large, tough curds. Whey 
protein is not coagulable by rennin, therefore is the best form of protein 
to give the infant, since it does not form curds. 

CALORIC FEEDING. 

This is a method of providing nourishment for the infant by giving 
it a food which contains the number of calories suitable for the 
individual case; but the caloric requirements of an infant are in- 
fluenced by so many different factors that the caloric method of feeding 
is not practicable. It offers, however, a method of determining whether 
a child is overfed or underfed, and can be employed when an infant 
suffers from persistent gastro-intestinal disturbances, or whenever a 
baby fails to thrive. 

The large calorie, which is the amount of heat necessary to raise 
one kilogram of water 1 c.c, is the one used in infant feeding. The 



180 INFANT FEEDING 

normal infant requires from 100 to 120 such calories per kilogram of 
its body weight during the first six months in order to thrive. From its 
sixth month until it is one year old it needs 100 calories, and 90 
calories during the second year. 

The number of calories required by an infant in order that it may 
gain weight depends also upon its state of health. Fat babies never 
need more than 90 calories per kilogram, and the fatter they are the 
less calories they need in order to gain; while thin babies may require 
from 140 to 160 calories per kilogram in order to gain, and the thinner 
the baby the more calories necessary. 

Babies that have been underfed, or are recovering from some 
debilitating illness, also require temporarily more calories than healthy 
normal infants, and the active child needs more than the quiet one; 
so more food must be given the infant which cries most of the day and 
is restless at night than the baby that sleeps nearly all of both day 
and night. 

The caloric value of modified milk mixtures may be quickly deter- 
mined by means of the formula recommended by Fraley. The letters 
"F," "P," and "S" represent the respective percentages of fats, pro- 
teins, and sugar, and the letter "Q" the total quantity of food. This; 
formula follows: 

2F + P + S X 11Q = Calories. 

The caloric value of a 20-ounce mixture containing 3 per cent, fat, 
1 per cent, protein, and 6 per cent, sugar can be calculated as follows: 

2 x F (3) = .6 + P (1) = 7 + S (6) = 13 X HQ (25) = 325 calories. 

HOME MODIFICATION OF MILK. 

Milk can be prepared at home with such accuracy that most infants 
will thrive upon it, and percentage formulas are easily obtained. The 
excuse is sometimes made that modification of milk is too difficult a 
procedure to be attempted at home, but I have not found this to be 
the case. 

The actual quantity of the various food elements to be used must 
be carefully calculated, however, instead of merely writing percentages 
on a prescription blank, and the mother must be told just how much 
cream, skimmed milk, water, lime-water, and sugar of milk to use. 
She must also be instructed how to secure a certain percentage of fat 
cream from the top of a quart bottle of milk. A 4 per cent, fat milk 
will, upon standing, yield 12 per cent, of fat in the upper 8 ounces of a 
quart bottle, 20 per cent, of fat in the upper 5 ounces, and 16 per cent, 
of fat in the upper 6 ounces; and with cream of these varying degrees 
of fat content most milk mixtures can be made. A cream dipper should 
be used to obtain the cream, and the fat-free, or skimmed, milk should 
be gotten from the very bottom of the bottle. 

In measuring the milk sugar a rounded tablespoonful is considered 
to weigh half an ounce. Therefore, in prescribing a modified milk 
mixture to be made at home, the physician not only states the exact 



LABORATORY METHOD OF MODIFICATION OF MILK 1 si 

percentage of the various food elements to be used, but estimates the 
quantity of each ingredient to be put in the mixture, and write- In- 
directions accordingly. Such a prescription follows: 

Cream (12 per cent, fat) 5 ounces 

Fat-free milk 3 ounces 

Sugar of milk 2 tabieepoonf uls 

Lime-water 1 ounce 

Water (boiled) enough to make 20 ounces 

Three ounces of this may he given every three hours. Any percentage 
of cream may be used, but, for practical purposes, as well as economy, 
it is generally advisable to make our home modification with 

12 per cent, cream 
Fat-free milk 
Milk sugar 
Lime-water 
Water 

With these ingredients almost any desired percentages may be obtained. 

LABORATORY METHOD OF MODIFICATION OF MILK. 

The physician who has the advantage of proximity to a milk labora- 
tory in which milk formulas are prepared must first decide what 
percentage of fats, carbohydrates, and proteins will be suited to the 
infant's case, and how much he wishes to give the infant in twenty-four 
hours. The amount to be given at each feeding should be determined, 
and the caloric value of such a mixture also calculated, in order that 
the infant may be neither overfed nor underfed. 

The amount of protein in a mixture for the newborn infant must 
be extremely small, and very little fats should be given. The carbo- 
hydrates are reduced to 5 per cent, for the first few weeks, after which 
6, and later 7 per cent, are prescribed, and this latter percentage remains 
practically stationary throughout infancy, although the percentage of 
fats and proteins is increased at various intervals. In addition to 
determining the percentage of these various food elements, the phy- 
sician must decide what kind of sugar is to be used, also whether or 
not part of the protein shall be in the form of whey protein. 

He must also decide whether or not an alkali shall be added, and 
whether the milk shall be given raw, pasteurized, or boiled. Having 
decided all these points, it is only necessary to write a prescription 
on the blank furnished by most laboratories, stating what the com- 
position of the formula is to be, and how often it is to be given. 

There is no doubt that the milk laboratory prepares the milk 
mixture more accurately than does the mother, but the expense 
attached is too great for poor people. A table, giving approximately 
the composition and percentages of milk mixtures, with the number of 
feedings at different ages, is here given. But the physician must 
remember that no two infants can be fed alike, and that these figures 
are only approximately correct for the normal healthy infant. A form 
of prescription blank to be used in conjunction with laboratory 
modification is here appended. 



182 



INFANT FEEDING 



It- 
Fats 



Date 



Carbohydrates. 

Dextrinize 
Proteins 
Peptonize 
Sodium citrate 

Sodium bicarbonate 

Lime-water 

Lactic acid bacilli 
Heat at ° F. 

Number of feedings 
Amount at each feeding 



lactose. 

maltose. 

sucrose. 

dextrose. 
[ starch. 

whey. 

casein. 

per cent. 

per cent. 

per cent. 
\ per cent. 

per cent. 

per cent. 



of milk and cream, 
of total mixture, 
of milk and cream, 
of total mixture, 
of milk and cream, 
of total mixture. 



M.D. 









Amount at each 


co 






Total quantity, 




_^ 








feeding. 


M 






24 hours. 




a 

CD 












T3 
CD 
CD 


CO 


co 








a 
























a 


13 






3 


"3 












"o 


'£ 


> 






"3 


CD 






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These formulas should all contain 5 per cent, of lime-water. 



CARE OF BOTTLES AND NIPPLES 183 

FEEDING AFTER THE WEANING PERIOD. 

From the ninth to the twelfth month the food should consist of 
whole milk diluted with one-seventh its hulk of water. In addition 
cereals, such as Imperial Granum, oatmeal, and cream of wheat may 
be given once daily, and orange juice and beef juice three times a week. 

From the twelfth to the eighteenth month the child is fed four or 
five times daily, and may be allowed soft-boiled eggs, plain crackers, 
bread and butter, milk custards; clear beef, mutton, or chicken sou]); 
prune juice, baked apple; baked potato. When all of the teeth have 
appeared, and the food can be properly masticated, lamb chop, white 
meat of chicken, and underdone beafsteak may be given, also green 
vegetables, such as beans, spinach, asparagus, potatoes, and peas. 

After the fifth or sixth year three or four meals arc sufficient, and 
the child may take well-cooked vegetable soups, meat, fish, poultry, 
fresh vegetables, ripe fruits, puddings, and ice cream once or twice a 
week. 

CARE OF BOTTLES AND NIPPLES. 

After use, all bottles and nipples should be scrubbed with very hot 
water and a brush, and put into cool, sterile water containing a little 
sodium bicarbonate. The bottles should be boiled for ten minutes 
just before the day's milk supply is prepared. 

The nipple should be of rubber, and thin enough to be easily turned 
inside out when cleansed. The opening should be only large enough 
to allow the milk to trickle out drop by drop when the bottle is inverted. 
Any complicated nipple or any tubing which extends into or from the 
nursing bottle is difficult to clean and positively harmful. 

It is usually unnecessary to cleanse the mouth of a child either before 
or after feeding, provided the oral mucous membrane is normal, the 
mother's nipple healthy, and that, if bottle-fed, the rubber nipple is 
properly cared for. If, however, the mother's nipple is sore, eroded, 
or cracked, and a nipple shield is not used, the child's mouth should 
be gently cleansed with plain sterile water just before feeding. 






CHAPTER IX. 
NORMAL DIGESTION. 

The newborn infant is not a perfectly developed individual, but 
is still in the stage of development. This is true as regards both its 
digestive organs and their functions. Yet these organs are called 
upon not only to sustain life by repairing tissue waste, as in the 
adult, but also to provide sufficient material for promoting growth 
and proper development. 

When we consider that during the first year of life the body weight 
must approximately be trebled, we understand why the delicate, 
immature digestive apparatus of an infant is so easily upset, and the 
importance of proper nutrition during this period becomes evident. 
In order to avoid overtaxing this immature function, Nature has 
provided in mother's milk all the necessary food elements in proper 
proportion and in assimilable form. She also furnishes lipase, dias- 
tase, and, in all probability, a protein-digesting ferment, as well as 
certain substances which no doubt act as protectives against diseases 
of the intestinal tract. 

The Oral Cavity. — The absence of teeth, the peculiar fat polster 
in the cheeks, which is seen even in marasmic babies, and other ana- 
tomical conditions plainly show that the oral cavity is at first intended 
for the reception of liquid food only, its mechanism being purely 
suctional. The child grasps the nipple between the tongue and the 
hard palate, and by a downward movement of the lower jaw, aided 
by the contraction of the muscles in the floor of the mouth and later 
on by deep inspirations, creates a partial vacuum, and thus the milk 
is made to flow from the galactiferous ducts into the nursling's mouth. 

Sucking is, therefore, only possible when the nose is free for respira- 
tion and the palate and the floor of the mouth are perfectly intact. 
Hare-lip, cleft-palate, nasal obstructions, and adenoids greatly inter- 
fere with nursing and may even make it impossible. The mouth is 
merely the natural entrance to the digestive organs, and at birth does 
not aid digestion by salivary secretion; although the salivary glands 
are present and apparently well-developed, their secretory function 
is not yet fully established, consequently the mucous membrane of 
the mouth is rather dry, the small amount of salivary amylase or 
ptyalin contained in the saliva clearly indicating that the latter is 
not ready to be utilized for starch digestion. 

After the third or fourth month — toward the beginning of den- 
tition—the salivary secretion increases markedly in quantity and its 
characteristic quality is intensified. Even then it probably plays but 
an insignificant role in digestion, because very little of it is swallowed, 



cast in c DIOESTION 185 

the greater pari flowing out of the mouth unused (drooling). Toward 
the latter part of the first year the ainylolytie function is fully estab- 
lished and is comparatively as active as in later life in the partial 
conversion of insoluble starch into soluble starch — erythrodextrin, 
achroodextrin, and maltose. 

Dry food stimulates the secretion of saliva, which is usually alkaline 
or neutral, while food containing much water excites but little Mow. 
Salivary amylase or ptyalin, the active enzyme of saliva, the digestive 
power of which is limited to starchy food, acts in a neutral medium, 
or in a slightly acid solution. It continues to act in the stomach 
until the gastric contents have been acidified, which occurs ordinarily 
in from one-half to one hour after a meal. It may be worth men- 
tioning in this connection that the reaction of the oral cavity has been 
found to be slightly acid in 95 per cent, of infants whose mouths had 
not been thoroughly cleansed after feeding. 

Dentition in the normal infant is of interest chiefly on account of 
the importance which parents are ever ready to ascribe to it as the 
cause of convulsions and gastro-intestinal disturbances. The erup- 
tion of the temporary teeth is a physiological process. The first tooth 
usually appears during the sixth month, but variations in time from 
the fifth to the eighth month are not abnormal. The remaining teeth 
appear in groups at more or less regular intervals in the following 
order: lower incisors, upper incisors, canines, and molars. At the 
age of two and a half years all of the teeth should have been cut. 
Teething is therefore an almost continuous process for about eighteen 
to twenty-four months. This fact alone shows the fallacy of attribut- 
ing to its influence diarrhea and other diseases which are merely 
coincidental. Forcheimer says, "Dentition produces teeth, nothing 
more." 

On the other hand, dentition may be painful, especially in the case 
of the narrow palatal arches so frequently seen in children suffering 
from adenoids or other nasal obstructions. Sometimes it takes a 
tooth days and weeks actually to penetrate the mucous membrane. 
A dry, hot mouth, a peculiar irritability, fretf illness, and other slight 
disturbances of health seem to occur so often during dentition that 
one cannot doubt a certain causal relationship between it and the 
other conditions; and it can be readily understood that infants with 
inherited neurotic and spasmophilic tendencies may show even more 
severe symptoms of disturbance of their unstable equilibrium. ■ 

The sense of taste is well developed at birth, and probably that of 
s))iell also. 

There is little to be said about the esophagus except that its epithel- 
ium is soft and delicate, and that the glands are usually lacking. 

Gastric Digestion.— Gastric digestion has been said to be insignificant 
in infants, the stomach serving merely as a reservoir for the milk, 
which is passed into the intestines at convenient intervals, and in 
such quantities as the duodenum can best take care of. AYhile it is 
true that the organ does not play so important a role in the digestion 



186 NORMAL DIGEST TON 

of infants as in that of adults, and that its mechanical and chemical 
processes are only preliminary to intestinal digestion, it has been con- 
vincingly demonstrated by Pawlow and his school that the functions 
of all the different parts of the digestive apparatus are interrelated 
and dependent upon each other to a great extent. 

A description of a single physiologic function must, therefore, be 
more or less incomplete unless due consideration be given at the same 
time to all of the other supplementary or complementary processes 
involved. The process of digestion in infants, on the whole, is by no 
means as yet clearly understood, in spite of the most painstaking and 
elaborate investigations. 

The majority of observations and conclusions are based either on 
lavage of the infant's stomach, limited necessarily to short periods, 
or on animal experimentations. The latter are of comparatively little 
use, because animals suffer little from digestive disorders, their diges- 
tive organs being much more fully developed at birth, and they can 
assimilate adult food at a much earlier period of their lives than do 
infants. 

Moreover, it must be borne in mind that even apparently normal 
infants differ individually as to their digestive capabilities, at least as 
much as adults, and that in different infants the secretory functions 
are not equally developed in the formative stage of the first vear of 
life. 



GASTRIC DIGESTION (ANATOMICAL AND PHYSIOLOGICAL 
PECULIARITIES). 

Considering the ease with which infants vomit, the position and 
form of the stomach are matters of interest. Its position is more verti- 
cal than oblique, the cardiac end is well fixed, and is slightly to the 
left of the tenth dorsal vertebra; the more freely movable pylorus is 
located at a point half way between the ensiform cartilage and the 
umbilicus, and in front or even slightly to the left of the spinal column. 
In form it stands midway between the tubular type of fetal life and 
the pouch-like adult organ. 

At birth the stomach is rather small, its fundus and muscles being 
only, slightly developed, but it grows rapidly, except when insufficient 
quantities of food are given for a prolonged period. The peculiarities 
of the adult shape and position appear in early childhood, and it is 
noteworthy that the pyloric opening is proportionately much wider 
during the first year than it is in later life. 

The problem of gastric capacity has not been definitely solved by 
any system of measurement. This is probably no loss, from a clinical 
point of view, for, as a rule, an infant instinctively ceases to feed before 
its stomach is mathematically full. The capacity is said to be greater 
in the artificially fed baby than in the breast-fed infant (we think 
not necessarily so when properly managed), and to increase rapidly 
during the first three months, slowly in the fourth, practically not at 



GASTRIC DIGESTION 187 

all during the next two months, and then again increasing until the 
adult size is attained, as is shown in the following table: 

At birth 1 ounce 

At four weeks . 2\ ounces 

At eight weeks 3| " ■ 

At three months 4 

At four months 5 " 

At five months 5i 

At six months b\ 

At seven months 6j " 

At eight months 7 

At nine months 1\ " 

At ten months 7f " 

At eleven months 8f 

At twelve months 9 

For practical purposes it is sufficient to remember these figures: 

At birth 1-2 ounces 

At three months 4 

At six months 6 

At twelve months 9 

The stomach is a muscular organ. Its motor function is chiefly 
exerted in mixing the food and expelling it into the duodenum in proper 
quantities and at convenient intervals. According to Cannon, the 
pyloric mechanism seems to be controlled by hydrochloric acid. A 
certain acidity of the stomach contents in the pyloric region, due to 
its admixture with free hydrochloric acid, causes the pylorus to open, 
while an acid reaction on the duodenal side causes it to close and to 
remain closed until the acid is neutralized. A high fat percentage 
retards the passage of food through the pylorus. 

Pawlow has demonstrated that the quantity and the properties of 
the digestive secretions vary with the character of the food to be 
digested; that is, the secretions produced by different kinds of food 
vary in amount, in acidity, and in their digestive action. Quite apart 
from psychical stimulation, it seems that certain foods when taken into 
the stomach cause a secretion of the gastric juice owing to the secre- 
togogues they contain. Meat extracts, soups, water and meat juices 
are especially active; milk, and egg albumen, less so. 1 

The gastric secretion begins about five to seven minutes after the 
ingestion of food, and increases rapidly, reaching its maximum of 
digestive power in about two hours, after which the flow rapidly 
decreases. The development of the glands in the mucous membrane 
of the stomach is rarely equally advanced in infants of the same age. 
Every baby is a law unto itself in this respect, as well as in respect 
to its digestive and other assimilative powers; in other words, there 
exist individual differences in the development of the gastric, the 
glandular, and digestive functions of the infant which to some extent 
explain the different findings of various investigators. 

1 The secretion produced by bread, though less in quantity than by meat, possesses a 
greater digestive, action. 



188 NORMAL DIGESTION 

The acid reaction of the stomach contents in the normal infant is 
due to hydrochloric acid, the presence of which can be easily proved 
and its quantity determined. Lactic acid, probably produced by the 
fermentation of carbohydrates (milk sugar), has not been definitely 
shown to be a normal constituent, and indeed some authorities con- 
sider its presence in the stomach as pathological. 

Of course, there is a possibility of other acids being formed in the 
stomach, for example, by the action of bacteria on food; but, accord- 
ing to our present knowledge, the hydrochloric acid alone is of real 
physiologic importance. The ingested milk excites the secretion of 
hydrochloric acid, 1 which then combines with the proteins of the food. 

This occurs in the healthy breast-fed infant in one and a quarter to 
two hours after nursing, in the baby fed on diluted cow's milk it takes 
not less than two to two and a half hours, while with whole milk the 
process is still longer delayed. Free hydrochloric acid undoubtedly 
exerts an antiseptic, and, if sufficiently concentrated, even a bactericidal 
power. 2 

Although not of great importance this power is sufficient to add 
one more to the many advantages of breast-feeding. Inasmuch as 
mother's milk requires less acid for combination, one-half to one-third 
of that of cow's milk, the amount of free hydrochloric acid normally 
present is sufficient as a bactericidal and, as is sometimes claimed, 
also a detoxicating agent. 

The extent to which pepsin combined with hydrochloric acid assists 
in protein digestion depends upon the consistency and the character 
of the food, and the length of time it is retained in the infant's stomach. 
Although some of the protein is, no doubt, acted upon and partially 
peptonized, the bulk of it in all probability passes almost unchanged 
in the chyme into the duodenum together with primary and secondary 
proteoses and even some peptone. 3 

As all gastric processes are merely preliminary to, and important 
for, subsequent digestion, so the true value of peptic action lies in its 
combination with trypsin. This enzyme is said to split proteins which 
have been submitted to the action of pepsin and hydrochloric acid in 
a way different from that which takes place with food not so prepared. 
The fact that a low temperature retards the action of pepsin shows the 
importance of giving food at a proper temperature, preferably from 
100° to 105° F. 

Wherever proteolytic enzymes may be found in the body there is 
evidence of a milk-curdling function; therefore the analogy has been 
drawn that curdling in the stomach is said to represent an action of 
pepsin itself, and is not due to a specific ferment. However, the con- 
sensus of opinion attributes the coagulation of milk in the infant's 

1 A weak infusion of tea and albumin water produces little secretion of hydrochloric 
acid. 

2 Free HC1 0. 132 to 0. 158 inhibits growth of typhoid bacilli ; free HC1 0. 185 kills growth 
of typhoid bacilli; free HC1 0.08 inhibits growth of cholera bacilli; free HC1 0.10 kills 
growth of cholera bacilli. 

3 The latter may, however, result from the action of bacteria in the stomach. 



GASTRIC DIGESTION L89 

stomach to a ferment variously called rennet, lab-ferment, chvmosin, 
rennins or pexin. 1 It is supposed to be present in the glands as pro- 
rennin, which under the influence of acids is converted into rennin. 
This acts upon the casein of milk, producing soluble paracasein, whirl) 
in its turn reacts with the soluble calcium phosphates of milk. As 
a result the insoluble salt, calcium-paracasein, is precipitated in the 
form of curds, which differ considerably in the breast-fed and in the 
artificially-fed baby. 

Undiluted cow's milk is said to curdle in rather compact masses 
containing much fat entangled in their meshes, and making it less 
digestible; in fact, large coagula are still to be found in the infant's 
stomach half an hour after feeding. Barley, oatmeal, rice, or arrow- 
root-water added to the food are said to cause curds with finer flocculi 
and thus to facilitate digestion. 

Mother's milk, on the contrary, coagulates quite imperfectly and 
in fine flakes, enclosing only a little fat. Half an hour after nursing, 
the gastric contents of a breast-fed baby are seen to be a homogeneous 
mass which can be more easily acted upon by the digestive juices than 
the dense coagula of cow's milk. As regards the coagulation time, 
mother's milk is almost neutral, and coagulates only after its alkalinity 
has been sufficiently reduced; this requires about one-half to three- 
quarters of an hour, while cow's milk, being acid from the beginning, 
curdles much earlier. 

Rennet coagulation does not invariably take place, nor i> it always 
complete, but is influenced by the composition, the dilution, and the 
temperature of the milk, as Avell as by the presence in the stomach of 
clots from previous feedings. Curdling is hastened by warmth, and 
occurs most promptly at 106° to 108° F. with the addition of an inert 
foreign matter, such as starch, etc., and by the presence of acids, as 
well as of certain acid salts. It is retarded when the amount of soluble 
calcium salts is relatively decreased, as hi diluted or heated milk, and 
when alkalies or alkaline salts, such as sodium chloride or lime water, 
are added to the milk. 

Xo coagulation at all takes place with rennet when the soluble 
calcium salts are completely removed, and since boiling the milk 
decreases their amount considerably it must also materially affect 
the curdling process. The action of rennin is limited to coagulation. 
The digestion of the curd is carried on to a small extent by the com- 
bined action of pepsin and hydrochloric acid, and is practically com- 
pleted by trypsin with the formation of proteoses, peptones, peptids 
and amino-acids as in other proteins. 

The formation of curds seems to be the effort of Nature to throw part 
of the burden of protein digestion upon the stomach by delaying the 
passage of the food into the duodenum. This function of digestion 
should therefore be encouraged, as it probably influences the muscular 
development of the organ to a considerable degree. 

1 Casein is also precipitated from milk by an excess of acid as is seen in sour milk 
(lactic acid.) 



190 NORMAL DIGESTION 

The duration of gastric digestion varies with the age and the 
development of the child, as well as with the quantity and the quality 
of the food taken. At one month the stomach of a healthy breast-fed 
infant ought to be empty in from one to one and a half hours after 
nursing, and in about two hours up to the eight month; cow's milk 
requires one-half to one hour longer. 

During the first months the gastric contents pass with comparative 
rapidity into the duodenum; but, as the stomach increases in size and 
larger meals are taken, the food remains longer within it. All fluids 
except alcohol, which is only partially absorbed, begin to leave the 
stomach very soon after a meal, and a considerable amount passes 
the pylorus during the first half hour. Proteins in various stages of 
digestion follow, while the fats are ejected last of all. The higher the 
proportion of fats, the longer is the food retained in the stomach and 
the smaller is the amount of gastric juice secreted. 

Absorption in the Stomach. — Absorption does not take place readily 
in the stomach, for at least 80 per cent, of it occurs in the small intes- 
tine; it may, however, be somewhat increased by the ingestion of 
alcohol and certain condiments. Water, when ingested alone, is prac- 
tically not taken up at all, but quickly passes on into the intestines. 

Investigations concerning soluble salts are still incomplete, but it 
seems certain that they are not absorbed, at least not to any extent, 
until they reach a certain definite concentration. Peptones, peptids, 
and amino bodies are present only in minute amounts, but they can 
be and are absorbed, especially when in highly concentrated solutions. 
Fats are liquefied, partly emulsified, and perhaps to a small extent 
split up, but their intestinal digestion only is of importance. A small 
proportion of sugar is, no doubt, also absorbed by the gastric mucous 
membrane. 

In summarizing, we may say that very little absorption takes place 
from the stomach directly: a certain proportion of sugar and of salts 
and a small amount of nitrogenous material are absorbed, but prac- 
tically no" water and no fat. 

ANATOMICAL AND PHYSIOLOGICAL PECULIARITIES OF 
THE INTESTINES. 

In infants the intestinal tract, which develops from a mere loop 
loosely attached to the posterior abdominal wall, and which is still 
in the formative stage after birth, is found to be less fixed than in 
adult life. Its elastic tissue is only slightly developed, the musculature 
is thinner and weaker, and there is relatively less difference between 
the diameters of the large and the small intestines. These peculiarities 
explain the ease with which the bowels become distended, and the 
pronounced tendency to constipation, colic, and, last and most impor- 
tant, to intussusception. 

The intestinal villi are well developed; Peyer's patches are found 



PECULIARITIES OF INTESTINES 191 

very early, while Brunner's glands are said to be less abundant than 
in adults. The small intestine is, oil an average, about nine feet long 
at birth, and this length increases during the first two months by 
about four feet, making it relatively longer than in the adult. The 
length, however, may vary greatly, depending partly upon the quan- 
tity and the kind of food taken. This is illustrated by the faet that 
among the poorer classes in Russia, who of necessity live almost 
exclusively upon vegetables, the intestines are found to be considerably 
longer than among other people. 

At birth the length of the large intestine averages about one foot, 
ten inches, which is about the height of the body. The sigmoid 
flexure is situated higher than in the adult, only one or two of its 
loops curving down into the pelvis; it is usually half the length of the 
large intestine. The colon, however, grows more rapidly, so that at 
the end of the fourth month it has about reached adult proportions, 
its relatively broad mesentery allowing full displacement. The cecum 
also occupies a higher and more median position than in the adult 
and is very mobile. The ascending colon is very short, and practically 
free, as a relatively large part of it is invested with peritoneum. The 
descending colon often has no mesentery; the length of the appendix 
is variable, and its position most uncertain. 

The size of the pancreas at birth is still a matter of discussion. 
It shows no special anatomical features; its secretion is alkaline in 
reaction, and is stimulated as acids come into contact with the duodenal 
mucous membrane. It begins to flow very soon after food has entered 
the stomach, and reaches its maximum in from two to four hours. 
The amylolytic enzyme (pancreatic amylase) acts similarly to ptyalin 
(salivary amylase), but both its amount and its activity are said to 
be limited at first; its function seems fairly well established in the 
second half of the first year, and in an infant of six months it can 
safely be called upon for the digestion of moderate quantities of 
starch. 

In the early months of life the power of pancreatic lipase (steapsin) 
seems to be only slight, but it increases gradually, and reaches its 
full development toward the end of the first year. This ferment does 
not act rapidly unless aided by bile, but it emulsifies, saponifies, and 
finally splits the fats into glycerin and fatty acids, thus fitting them 
for absorption by the intestinal epithelium. By the action of the 
same enzyme, they are probably recombined to form neutral fats 
which are used in intermediate metabolism. A milk-curdling ferment 
has been described. 

Trypsin like pepsin causes hydrolytic cleavage of proteins, but its 
effects are more rapid and more powerful, and it requires an alkaline 
medium. The actual products formed depend to some extent upon 
the length of time and the special conditions under which trypsin 
acts; i. e., proteins are said to be more rapidly and more completely 
broken up when they have been previously acted upon by pepsin. 



192 NORMAL DIGESTION 

Trypsin attacks the protein molecules and apparently breaks them 
np into their end-products — amino-acids. Such peptones, proteoses 
or peptids as may have escaped its final action are acted upon by the 
erepsin of the succus entericus before reaching the blood. 

Thus the proteins are almost completely disposed of under normal 
conditions and the nitrogenous substances which are found in the 
feces of a normal infant are principally mucus, bacterial residues of 
secretions, and epithelial cells. 

In disease of the intestine the pancreatic juice seems to lose its 
proteolytic and some of its fat-digesting properties, while its diastatic 
function is said to be less disturbed. 

The liver is proportionately large in infancy and childhood, being 
about one-eighteenth of the entire body weight as compared with 
the adult proportion of one-thirtieth; its lower border can normally 
be palpated one-half to one inch below the costal margin in the mam- 
mary line. This relatively large size and weight indicate that it per- 
forms a very important function and that it is well adapted to the 
great metabolic activity of this period of life. 

It may not be out of place to revert to the fact that all material 
coming from the intestines by way of the blood must pass through 
the great hepatic filter. While it has been definitely proven that 
the glycogenic function, the formation of urea from ammonia, and 
the secretion of bile exist in the newborn babe, it seems that the 
hepatic efficiency for destroying poisons is not thoroughly established 
in early infancy. 

The secretory function of the liver is developed as early as the third 
month of intra-uterine life, when both bile salts and pigments find 
their way into the intestine. At birth they are evidently in the 
meconium. The bile, relatively abundant in infants, presents no 
essential difference in its action from that of the adult. Some writers 
believe that its composition is deficient in organic salts, and also that 
it contains a smaller percentage of cholestrol, lecithin, glycocholic 
and taurocholic acids. 

Bile salts are believed to have the property of aiding in the emul- 
sification and the cleavage of fats. The small proportion of bile salts 
present during infancy accounts for the feeble antiseptic power of the 
bile, and for the consequent fermentation of the intestinal contents, 
as well as for the incomplete absorption of very fatty foods. Perhaps 
the resulting fatty acids irritate the intestinal mucous membrane, 
and thus disturb digestion. 

Succus Entericus. — The secretions from the follicles of Lieberkiihn 
and from Brunner's glands are alkaline, and are stimulated by the 
ingested food, which is then subjected to their chemical action. The 
following enzymes have been isolated from the mucous membrane 
of the walls of the small intestine : 

1. Enterokinase, which converts trypsinogen into trypsin. 

2. Erepsin, which digests products of protein digestion that may 



ABSORPTION IS THE INTESTINES VX\ 

have escaped the action of trypsin; e. g., proteoses, peptones and pep- 
tids; it also digests casein of milk. 

3. Inverting ferments. These are as follows: Maltase, which con- 
verts maltose into dextrose. Invertase or sucrase, which converts 
cane sugar into dextrose and levulose. Lactase, which converts 
milk sugar into dextrose and galactose. 

The intestinal canal of the newborn infant does not differ so much 
anatomically as it does functionally from that of later life. The 
gastric contents, after having been propelled through the pylorus 
into the duodenum, are mixed with, and subjected to the combined 
action of, the bile and the pancreatic and intestinal juices. It is in 
the small intestine that the most profound changes occur, and the 
products of digestion are mainly absorbed. By the time the food 
arrives at the ileocecal valve these processes are practically complete. 

Absorption in the Intestines. — Chyme, or the stomach content- 
passed into the infant's duodenum, is chiefly composed of watery 
elements containing sugars, salts, etc., in solution. The proteins 
are partly unchanged (casein coagula), and partly appear in the form 
of acid metaprotein, proteoses, and peptones. Fats pass into the 
intestines suspended in fluids or entrapped in the meshes of casein 
curds. The acidity of the chyme, due chiefly to HC1, is neutralized 
by the pancreatic and intestinal juices and the bile. 

About 80 per cent, of all absorption takes place in the small intes- 
tine, which accounts for the fact that disturbances in this part of the 
digestive tract, with their concomitant diarrhea and frequent watery 
passages, are followed by extremely rapid wasting and exhaustion. 
Proteins are supposed to be absorbed in the form of amino-acids, 
and in healthy breast-fed infants this absorption takes place almost 
entirely in the upper part of the small intestine; only traces of protein 
are found in the lower ileum. The reaction of the upper part of the 
gut is slightly acid. In artificially fed babies the digestion and the 
solution of casein are less complete in the duodenum, and the reaction 
is distinctly acid. 

Pancreatic lipase (steapsin), assisted by bile, splits fats into fatty 
acids and glycerol and also saponifies and emulsifies them. In these 
forms they are readily taken up by the intestinal villi, but become 
converted into neutral fats during their passage through the mucous 
membrane. Fats are not completely digested and absorbed in the 
intestines of infants, considerable being excreted in the feces as neutral 
fats and fatty acids. 

The sugars are taken up as dextrose, which is the most readily 
absorbed monosaccharide. Galactose and levulose must undergo a 
further process of inversion to dextrose before they can be taken up. 
It would thus appear that maltose, which splits into two molecules 
of dextrose, may be absorbed more readily than either lactose or 
saccharose. There is still a difference of opinion as to whether pan- 
creatic amylase (amylopsin) is active in early infancy; later on it 
can and does convert starch into maltose, as shown on next page. 
13 



194 NORMAL DIGESTION 



Starch 

I 
Soluble starch 



I I 

Erythrodextrin Maltose 



I 1 

a-Achroodextrin Maltose 

i '■ ■ i 

/3-Achroodextrin Maltose 



I I 

7-Achroodextrin Maltose 

I I 



Maltose 

In the large intestine little else but water is absorbed, so that an 
infection of the colon alone produces comparatively little wasting. 
Fat absorption is slight, while sugars, salts, and peptones may be 
absorbed with moderate facility; therefore, in rectal feeding the food 
should be thoroughly predigested. 

The stools of infants and of children are a delicate index of the 
state of the digestive functions, and a careful examination of the 
feces in conjunction with other clinical observations will give us a 
fair idea as to whether the food is being digested and assimilated. 
In order to detect abnormal conditions it is necessary to be thoroughly 
familiar with the characteristics of normal evacuations. Normal, 
of course, does not mean uniform; it is well known that even in a 
perfectly healthy infant the stools may at times vary in color and 
consistency, and may even contain coarse white particles. This is 
not astonishing when we consider that even such an ideal food as 
mother's milk is not always uniform in composition, especially in its 
percentage of fat. 

During the first two or three days after birth the infant has about 
four to six passages of semisolid, dark, brownish-green meconium. 1 
These may continue for a week, but they usually begin to change in 
character on the third or fourth day, and soon assume the usual appear- 
ance of the healthy feces of the breast-fed infant. These discharges 
contain mucus, fats, epithelial debris, and a small portion of albuminous 
matter, their normal amount varying between two and three ounces 
per day. They are golden-yellow in color, owing to the presence of 
bilirubin, are homogeneous, of butter-like consistency, with an acid 
reaction, and a slightly acid odor, probably due to lactic and fatty 
acids. The small whitish curd particles already referred to — the 

1 Meconium is composed of intestinal mucus, bile, vernix caseosa, epithelial cells, 
hairs, fat globules, and cholesterol crystals. 



BACTERIA IN THE INTESTINES 195 

so-called milk granules of Uffelmann — are not albumin, but fat crys- 
tals and zooglea of bacteria. 

Normal milk feces contain about 85 per cent, of water and 15 per 
cent, of solids, mostly fats. Hydrogen and carbon dioxide are the 
only gas constituents; H 2 S and marsh gas are never present. Protein 
is almost entirely absent, the minute quantities which may have 
escaped solution and digestion being transformed by the intestinal 
bacteria into indol, skatol, phenol, and ammonia. 1 Fats occur in 
the form of fatty acids, soaps, and neutral fats, and form from 10 to 
20 per cent, of the dry residue of milk feces. Sugar is absent, but its 
derivative, lactic acid, may be encountered in small amounts, while 
starch may appear unchanged in the stools. The inorganic salts are 
chiefly represented by the calcium salts, and the biliary elements by 
hydrobilirubin, unchanged bilirubin, and cholesterol. 

In addition to these the feces contain much mucus, immense num- 
bers of bacteria, and various products of bacterial germination. The 
stools number from three to six per diem during the first month, 
afterward decreasing to from one to three, and later on to one daily 
movement. The stools of the bottle-fed baby are larger in bulk and 
contain less water than those of the breast-fed infant; they may also 
be more frequent, as many as four or even six being compatible with 
health as long as their consistency and color remain normal. The 
number of stools is merely an indication of the amount of intestinal 
residue, and not of disease. 

In a baby fed on cow's milk that has been perfectly digested, the 
feces may closely resemble those of the breast-fed child, but usually 
they are firmer, paler, and putty-like, with a neutral or alkaline reac- 
tion, and slightly offensive odor. Infants fed on malted or farinaceous 
foods have more or less dry and broken-up movements, yellowish- 
brown in color, and slightly alkaline, with a malt-like odor. 

The stools are never fully formed until a mixed diet is given. The 
peculiar character of milk stools then disappears, the feces become 
darker and emit the adult odor, but are softer than the latter. The 
reaction of the fecal discharges is still a matter of discussion. As a 
rule, it is acid in the breast-fed baby, while in the bottle-fed baby it 
is said to be feebly alkaline or neutral, provided the cow's milk is well 
digested; but if the fat percentage of the milk is too high or if more 
carbohydrates are given than can be digested, the reaction becomes 
acid. 

Bacteria. — Experiments and investigations concerning the bacteria 
which inhabit the intestines are as yet incomplete, and probably will 
be so for some years to come. After all, what would be gained if we 
could really distinguish and study each variety separately? Consider- 
ing that every species existing in the intestines is influenced in its 
development and its function by other varieties and groups actually 
present, or temporarily predominating, it seems more important for 

1 The nitrogen content in these feces is derived chiefly from the intestinal secretion 
and from the bodies of bacteria, 



196 NORMAL DIGESTION 

practical purposes to study the chemical changes produced in intes- 
tinal secretions and in the ingested food by the combined action of 
all the microorganisms living in the intestines. 

What changes are known to be bacterial in origin? In the normal 
breast-fed infant the intestinal flora are almost constant. To begin 
with, bacteria are absent from the gastro-intestinal tract at birth, 
but twenty-four hours later they have effected an entrance through 
the mouth and rectum. When breast milk is exclusively used the 
principal organisms present are: Bacillus aerogenes, Bacillus coli 
communis, and Bacillus bifidus, although as many as 19 different kinds 
have been isolated from the stools of healthy nurslings. 

Their number and distribution vary considerably in different parts 
of the gut, relatively few being found in the small intestine, while 
they flourish in the cecum and the colon. In the healthy baby they 
serve a useful purpose by aiding in the digestion of the food elements. 1 
Their most important role, however, seems to consist in producing 
the acid fermentation which prevails in the intestines of the breast-fed 
infant. This lessens the development of other harmful microbes, 2 
and reduces their action considerably. 

As carbohydrates favor, the development of some of these normally- 
present, acid-producing bacteria, the putrefactive processes can be 
modified, and to some extent controlled, by means of a diet rich in 
carbohydrates and relatively poor in proteins. Aside from the bene- 
ficial effect of partial starvation induced by such a diet, it in a measure 
explains the value of carbohydrate food in the early treatment of intes- 
tinal indigestion and also the temporary success which sometimes 
follows the use of condensed milk or similar foods. 

The great danger of nutritional disorders in infancy and childhood 
hardly needs emphasis. By lowering the power of resistance to 
disease, they directly or indirectly cause more deaths in this early 
period of life than all other illnesses combined. Disturbances of 
nutrition do not involve merely the processes of digestion and absorp- 
tion in the gastro-intestinal canal, but also the very important func- 
tions of assimilation and disassimilation, known as intermediary 
metabolism. 

A derangement of these processes not only hinders the normal 
function, but also retards the development of the immature body. 
The proper appreciation of this fact will enable us to realize the 
great importance of this subject, and will lead to the selection of the 
method of feeding most suited to the individual case. As the process 
of metabolism in older children progressively becomes like that of 
the adult we may confine our attention to the differences observed in 
the infant. 

To begin with, it must be acknowledged that the number of ascer- 
tained facts is small and that their clinical significance often seems 

1 Experiments have demonstrated that newborn animals, fed with sterilized food, 
remained decidedly backward; some of them could not even be kept alive. 

2 For instance, putrefactive bacteria, which thrive on the proteins of boiled milk, 



GASTRIC AND INTESTINAL SECRETIONS 197 

obscure. Wha1 then are 1 h<* abnormalities known to occur under 
pathological conditions within the digestive tract? As to the study 
of the changes in the gastric secretions, the stomach tube has con- 
siderably facilitated research in this direction. In almost all of the 
constitutional diseases of infancy, gastro-intestinal as well as febrile, 
the secretion of hydrochloric acid is greatly diminished, so much so 
that in many cases it is not present at all in the free state. This 
entails more or less complete loss of the antiseptic action of the 
normally present free hydrochloric acid. 

On the other hand, as regards therapeutics, it clearly demonstrates 
the necessity of longer intervals between feedings for the sick child, 
especially when cow's milk is taken, since the latter requires about 
30 per cent, more acid than does mother's milk. Hyperchlorhydria 
is found in rare conditions, such as congenital pyloric stenosis. This, 
however, is due to overproduction as well as to accumulation, favored 
by delayed evacuation of the gastric contents. Since the salivary 
amylase (ptyalin) and the gastric ferments, rennin and pepsin, are all 
secreted in sufficient quantity in sick children, it is evident that the 
administration of these enzymes by mouth would not prove very 
beneficial in these nutritional disorders. 

As for the other secretions, the detoxicating action of the liver in 
the infant has not been definitely proven, but there is good reason for 
accepting the statement that in the course of certain diseases the 
digestive power of the pancreatic secretions, and especially that due 
to trypsin and pancreatic lipase (steapsin) may be diminished. We 
know that the power of digesting starch is slight during the first few 
months of life; but as yet we know very little concerning the changes 
in the activity of the intestinal glands during illness, although duo- 
denal catheterization will no doubt aid us considerably in the future 
in gaining a clearer insight into this part of the body economy. 

In basing our conclusions upon these few facts, we scarcely feel 
justified in declaring that disorders of nutrition are identical with a 
disturbance in the digestion or the absorption of the various foodstuffs 
within the intestinal canal. On the contrary, it is well known that, 
even by very sick children, nitrogen and milk sugar are very well 
taken up; the milk sugar is absorbed unchanged only in exceptional 
cases, and then appears as such in the urine. 

As regards fats, there is no doubt that during illness a considerable 
amount passes unutilized through the intestinal canal to be excreted 
with the feces, either in the form of neutral fats — true fat diarrhea, 
which is rare— or as soap-stools, i. e., combined with alkalies. Free 
fatty acids too may be found predominating in the fecal discharges, 
but in none of these eventualities has the loss of fat been demon- 
strated to be so large as seriously to injure nutrition. 

The feV data which we possess concerning the excretion of mineral 
salts in the feces show that these bear no direct relationship to any 
definite disease. Normally, fermentation predominates in the intes- 
tines of the breast-fed infant, while putrefaction is present to a limited 



198 NORMAL DIGESTION 

extent in the bottle-fed baby. In certain pathological Conditions, 
however, putrefaction occurs with both types of feeding, its presence 
being confirmed by the offensive odor of the feces and the appearance 
of indican in the urine. 1 

Raw milk does not putrefy readily; indeed, its milk sugar may 
under favorable circumstances even prevent putrefaction; it is, there- 
fore, probable that the intestinal secretions themselves, increased by 
certain disturbances, furnish the material for putrefaction, especially 
in the bottle-fed baby. This process is also aided by the diminution 
or the complete absence of free HC1, which normally acts as an anti- 
septic. 

Whether or not the products of putrefaction can directly injure the 
organism is not definitely known. Since assimilation and retention 
of the necessary food-elements are essential for growth, the question 
arises, to what extent do pathological conditions influence these nor- 
mal functions? Again we must confess our limitations as to any know- 
ledge on the subject. There is no doubt that a certain amount of 
nitrogen is retained under practically all conditions, even when a" 
sick infant loses in weight, and it necessarily follows that at such 
periods other foodstuffs, especially fats, must pass through the body 
unutilized. Very often the fluctuations in the weight of the infant 
are so marked within short periods of time that these variations can 
only be explained by a pathological change in the watery content 
of the body. This is not surprising when we consider that more than 
60 per cent, of the total food assimilated consists of water. 

Phosphates originating from milk are usually well retained, even 
by a sick baby, while chlorides are apt to vary with alterations in 
the water content of the whole organism, or vice versa. An abnormal 
loss of lime may be a causal factor in defective ossification, as seen 
in rickets, and may, perhaps, play a role in the etiology of tetany, 
an affection in which the brain has been found to be exceptionally 
deficient in lime salts. 

The processes of disassimilation in the sick infant presumably differ 
from those in a healthy baby. Excessive oxidation is supposed to 
interfere with normal metabolism in atrophic conditions, where an 
infant with an excellent appetite loses weight instead of gaining. 
Certain disturbances during infancy, presumably intestinal in origin, 
but more often during childhood, lead to the excretion of acetone bodies 
through the lungs instead of in the urine, as in adult life. The con- 
comitant cyclic vomiting and fever, so frequent in older children, are 
often associated with the presence of considerable acetone in the 
urine. 

Keller, of Breslau, has demonstrated some interesting and practical 
facts for the diet of sick babies concerning the metabolism of mineral 
salts. It has been noted that the urine of infants suffering from cer- 
tain nutritional disorders often contains a relatively large amount 

1 Indican is absent in the urine of healthy breast-fed babies, but a small amount is 
present in that of healthy bottle-fed babies. 



FAT INDIGESTION 199 

of ammonia. Keller and his school claim that an excess of fat in the 
infant's 1 food combines with alkalies in the intestines and forms soaps 
which are excreted in the feces. The alkalies required for the neu- 
tralization of the inorganic acid end-products of metabolism are thus 
prevented from reaching their destination, and fulfilling their pur- 
pose, and Nature provides the necessary substitute in the form of 
ammonia which later appears in the urine. 

While it has not yet been definitely proven, it seems probable that 
an excessive loss of alkalies may lead to actual acidosis, and the 
injurious consequences of overfeeding with one food constituent are 
at "once apparent. The same investigators have by analogy, basing 
their conclusions upon their clinical observations, described similar 
food injuries occasioned by diminished tolerance of starch, sugar, 
proteins, and of whey salts. 

Czerny and Keller claim that the ingestion of fats, carbohydrates, 
proteins, and whey salts "beyond the point of tolerance" produces 
distinct symptoms resulting from food injuries, which concern not 
only the digestion and absorption, but also the intermediary metab- 
olism of the infant. This symptom-complex is of great clinical 
value, inasmuch as its recognition may obviate the prolonged starva- 
tion so frequent in chronic and acute indigestion. The mere with- 
drawal of the offending constituent from the food is sufficient to 
inaugurate improvement, and with proper care will insure a final cure. 

It must, however, be admitted that these symptom-groups are 
not always clearly defined. For instance, in the same individual 
there may be shown different degrees of tolerance for more than one 
food element. Likewise, in a given case, carbohydrates may be 
tolerated only when the food contains a low percentage of fats, or 
fats may be metabolized when the carbohydrates are cut down. 
Proteins do not seem to aggravate the intolerance for either fats or 
carbohydrates, but protein intolerance is aggravated by a higher 
percentage of either fat or carbohydrates in the food. 

The objection has been made that these subdivisions are too sche- 
matic. Possibly they are; but they have the great advantage of 
being practical and simple; for a correct diagnosis at the same time 
quite definitely indicates the proper remedy. At all events, they seem 
to be a step forward in emancipating us from the one-sided bacterio- 
logical viewpoint, and, though only a stepping-stone to the final solu- 
tion of the complicated problem of infant feeding, they are worthy 
of consideration. 

Fat Indigestion. — The proper amount of fat in an infant's diet is 
necessary for the production of teeth, for the regulation of the bowels, 
and for the nourishing and building up of the bony and nervous 
systems. Moreover, there exists an intimate relationship between 
fat metabolism and the resistance of the child to infection. It follows, 
therefore, that a baby may suffer more or less from malnutrition, 

1 This differs in different individuals according: to their digestive ability, etc. 



200 NORMAL DIGESTION 

anemia, lack of development, and decreased power of resistance to 
disease (rickets) either because of too little fat in the food or because 
of its inability to digest and assimilate the fat. Fat indigestion is 
very often due to overfeeding with rich milk or cream mixtures; oils — 
olive oil and cod liver oil — curiously enough, seem to create less 
trouble. 

In addition to the ordinary manifestations of indigestion, an excess 
of fat in the food causes ^ more or less distinct group of symptoms, 
such as malnutrition, coated tongue, fetid breath, and gastric dis- 
turbances, especially sour vomiting soon after feeding. The child 
looks pale, its complexion is muddy, and it often suffers from eczema 
and intertrigo of the buttocks. 

Constipation is the rule but this may alternate with diarrhea. The 
stools sometimes have a shiny, oily look (fat diarrhea) with a butyric 
odor. More often they are small, fragmentary, hard, dry, crumbly, 
and grayish- white in color; they then contain a large amount of 
insoluble salts, and do not soften even under the influence of a water 
enema. Microscopic examination of the feces reveals an excess of 
neutral fats, fatty acids, and soaps. The loose stools contain small 
soft curds, somewhat resembling scrambled egg. 

Colic is a frequent symptom, but it is usually caused by overfeeding 
or by undigested proteins. The urine is rather irritating, and smells 
strongly of ammonia. The more serious fat injuries, however, are 
uncommon except when the food contains an excess of both fats and 
sugars. The fat of mother's milk contains less fatty acids, 1 and is 
therefore more easily digested. This in a measure explains why an 
infant can assimilate mother's milk with its 4 per cent, of fat, while 
it may fail to digest the 2 per cent, fat in cow's milk, and also why 
the latter with its excess of acids may be readily converted into 
diacetic acid and acetone. 

Carbohydrates. — Sugars, being the most easily digested elements 
in the infant's artificial food, are liable to be increased at the expense 
of the fats and the proteins. Like fats, they serve as fuel, furnishing 
heat and supplying energy to the cells. While they may be partially 
converted into fats, and temporarily replace these,. a prolonged sugar 
diet will lead to serious disturbances. 

Most physicians, aware of the excess of carbohydrates in many 
proprietary foods which are so often advertised as substitutes for 
milk, advise against their use except in certain cases where, with 
the proper admixture of milk, they serve a useful purpose. By chang- 
ing the intestinal flora they are apt to create fermentation, 2 which, 
within limits, seems necessary for the proper functionating of the 
intestinal processes in infants. We say "within limits," because the 
products of excessive acid fermentation may irritate the mucous 
membrane, and thus cause purgation. 

1 Glycerides of butyric, caproic, caprylic, and myristic acids. 

- This fermentation cannot always be produced by starch alone, but sometimes requires 
the addition of sugar. 



I 'ROT FAX INDIGESTION 201 

Cereals, such as barley, rice, arrow-root, etc, arc useful even before 
the child is able to digest them perfectly, since they mechanically 
facilitate protein digestion by preventing the formation of very coarse 
casein curds. Some infants, it is true, can take a great deal of carbo- 
hydrate food with apparent impunity. They often look well and 
sturdy, and, although rather fat, they have a good color and tolerably 
firm flesh. The stools are yellow or brown, not green, and are often 
formed, and have an acid reaction. 

Except for a certain amount of meteorism, there seems to be noth- 
ing wrong with the baby, but should it be attacked by disease it shows 
very little power of resistance, thus confirming the every-day experience 
of the temporary character of the apparently good results of artificial 
feeding and its probable ultimate failure. 

As a rule, however, food containing an excess of carbohydrates 
soon leads to intolerance, indigestion, or to sugar intoxication, as 
indicated by loss of weight, flabby musculature, colic, nervousness, 
irritability, urticaria, and even fever. 1 The stools are numerous, 
watery, non-putrid, light green in color, and irritating to the skin 
of the buttocks on account of their acidity; they contain no curds 
and are passed with flatus. Gas formation producing tympanites, 
vomiting, and regurgitation of sour material is a common symptom. 

In more severe cases where the intolerance has been aggravated by 
prolonged dietetic errors, lactose, and frequently acetone and diacetic 
acid, may be found in the urine. These babies become thin, delicate. 
anemic; the tongue is coated, the appetite is poor or capricious, 
and they suffer from constipation, abdominal distention, and severe 
constitutional disturbance. With such patients sugar intoxication is 
commonly associated with an inability to metabolize whey salts. 

Treatment consists in eliminating the latter as well as the sugars 
from the diet temporarily, and when the symptoms have subsided, 
a different sugar in proper proportion should be cautiously added; 
maltose and dextrin are preferable, because they are not apt to produce 
fermentation, while milk sugar is prone to set up fever and diarrhea. 

Protein Indigestion. — While indigestion of proteins, especially the 
casein of cow's milk, does not seem to be so common as has generally 
been considered, its existence cannot be altogether denied. It certainly 
does occur, especially with foods having a high fat content, and is 
accompanied by the ordinary symptoms of intestinal disturbance, 
such as diarrhea, constipation, fever, colic, and sometimes even severe 
nervous manifestations. 

The stools in these cases are foul-smelling, alkaline, and occasion- 
ally contain curds, which, unlike those of fat indigestion, are usually 
hard, tough, and not friable. They are frequently oblong, rounded 
or bean-shaped, and vary in size from that of a lentil to a lima bean, 
while in their consistency and appearance they resemble hard American 

1 Sugar fever is similar to salt fever. In the body of infants, sugar seems to act much 
as an inorganic salt; being loosely combined and probably stored in the subcutaneous 
tissues, it favors the retention of water in the system. 



202 NORMAL DIGESTION 

cheese. The curds can easily be picked out of the napkin with a pin, 
washed and shaken about in water without being broken, and when 
dropped into water they sink to the botton. 

It is said that these casein curds disappear from the stools if a diet 
of boiled and diluted milk exclusively is given, and that they occur 
only in infants fed on pasteurized or raw milk with a low fat per- 
centage. The proteins alone supply the body with nitrogen, and no 
other food element can take their place, consequently the feeding of 
proper amount of proteins is of primary importance during early 
infancy — the time of rapid development. 

If, for therapeutic purposes, it becomes necessary to reduce the 
amount of proteins temporarily, they should be raised to the normal 
proportion as soon as possible in order to prevent anemia, loss of 
muscular tone and power, and circulatory disturbances. A food 
containing too little of both proteins and fats predisposes to constipa- 
tion and probably to rachitis. Whey proteins are very easily digested 
and rarely cause disturbance; any trouble they may set up is due to 
their whey salts. 

For many years attempts have been made to classify nutritional 
disturbances, but the results have been unsatisfactory, the grouping 
becoming more and more complicated and confusing instead of more 
simple. A mere clinical classification which takes account only of 
symptoms such as vomiting, constipation, colic, diarrhea, loss of 
weight, wasting, complications of dentition, etc., is, of course, not 
sufficient. 

Pathological study of the subject has cleared up much that was 
obscure, but the clinical course often differs widely in different indivi- 
duals in whom the anatomical and pathological changes are similar. 
In other, not exceptional, cases, the trivial morbid changes demon- 
strable postmortem bear no proportion at all to the serious symptoms 
observed during the course of the disease. Moreover, a classification 
based on a particular part of the digestive tract is not admissible, 
because of the intimate functional relationship of the various portions 
which may be involved at the same time or in rapid succession. 

Since Pasteur's discovery of the bacterial uncleanliness of food, 
bacteriologists have given us much information concerning the normal 
and the pathological intestinal flora as well as specific infections in 
infantile intestinal disorders. But these brilliant investigations have 
so far yielded relatively few practical results; at any rate, they have 
not enabled us to differentiate the various clinical pictures of nutri- 
tional derangement, nor, according to general statistics, does the 
mortality appear to have been materially diminished by either pas- 
teurization or sterilization of milk. 

Physiological chemistry teaches that disturbances of nutrition com- 
prise not merely local pathological processes in the gastro-intestinal 
tract, but represent conditions which affect the whole organism in 
that most vital function, intermediary metabolism. But, so long as 
the more intricate functions of normal nutrition are shrouded in 



NUTRITIONAL DISTURBANCES 203 

mystery, we certainly cannot hope to solve the etiological problem of 
its derangements, especially since idiosyncrasies, individual peculiari- 
ties, and special environment, such as beat, infection, and hospitalism, 
must be taken into consideration. Are these nutritional disorders 
due to defective digestion, faulty absorption, disturbed metabolism 
and assimilation, or to intoxication and decomposition? 

A serious and very important problem is the question of food 
anaphylaxis. It seems that this phenomenon even occurs in very 
young children so that they are abnormally sensitized toward the 
proteins of milk, for example, or a little later to those of the various 
foodstuffs. The recognition of this condition is still rather difficult, 
but the introduction of these substances in the diet will result in 
so-called anaphylactic shock, inducing colic, nausea and vomiting, 
diarrhea, and even fever, as well as various skin manifestations. 

It is only when scientific investigation along the lines of pathology, 
bacteriology, and metabolism goes hand in hand with mature clinical 
observation that we can hope to make any progress toward a solution 
of these questions. Czerny and Keller propose the following clas- 
sification, which is based not only upon scientific data, but is clinically 
of the greatest value to the physician in deciding upon the treatment 
of the case : 

1. Nutritional disturbances arising from alimentation. 

2. Nutritional disturbances arising from infection. 

3. Nutritional disturbances arising from congenital anomalies. 
"Proper nutrition makes for the perfection of the coming genera- 
tion, improper nutrition mars it. 1 ' How, then, is a baby to be fed in 
order to insure proper growth and development if it cannot have the 
advantage of the natural ideal food? The feeding problem in itself, 
full of difficulties, is often still further increased by a diversity of 
individual circumstances and idiosyncrasies which must enter into a 
consideration of the question of establishing an equilibrium between 
the quantity and the quality of the food and the infant's capacity to 
digest and assimilate it. 

In the perfectly normal infant the amount and the composition of 
the food may vary to a considerable degree without producing nutri- 
tional disturbances. This is owing to a great tolerance for the different 
food elements, and explains the common experience that a normal 
baby may thrive on a milk formula or on food which would cause 
serious trouble in another less robust infant. It is true that every 
infant is a law unto itself; nevertheless, there are certain rules for the 
guidance of the physician who prefers scientific methods to empiricism. 

Proper food must make possible a proper functioning of the intes- 
tinal mucous membrane, its glands and its adnexa. It should incite 
a sufficient peristalsis, and favor the growth of normal bacteria. It 
should be sufficient in amount to maintain the body heat, and so 
assimilable as to favor the building up of the body cells. Improper 
food, failing in one or more of these requirements, produces morbid 
changes in the gastro-intestinal canal that lead to derangement of 



204 NORMAL DIGESTION 

the intermediary metabolism, followed by disturbance of the general 
nutrition and, consequently, by a lessened power of resistance to 
disease. It must be emphasized that nutrition and nutritional dis- 
turbances are distinctly different in infants and children. 

The foods should contain fats, proteins, and carbohydrates in a 
fairly definite percentage, and in such proportions as will best meet 
the nutritional demands of the baby. If, for any reason, it is neces- 
sary to reduce the fats and proteins markedly they should be raised 
to normal as soon as possible. No other food element can take the 
place of nitrogen or proteins. Carbohydrates may temporarily 
replace the fats, but in time the lack of fat will produce serious nutri- 
tional disturbances. Too great reduction of proteins, fats, and salts 
may result in rickets, scurvy, anemia, and other forms of malnutrition. 

In artificially fed infants uncomplicated cases of under-nourish- 
ment resulting from simple lack of food are rarely seen. Usually 
they are referable to disordered absorption or assimilation, resulting 
in chronic indigestion, and originally brought about by improper 
feeding. Underfeeding may occur in the breast-fed child if the 
mother's milk is too weak in composition or too small in quantity or 
when some deformity, such as inverted nipples, etc., interferes with 
nursing. 

Hare-lip, cleft-palate, large adenoid vegetations, or debility may 
often prevent the nursling from getting a sufficient amount of milk, 
but this trouble is easily recognized and remedied. The infant fails 
to gain or even loses weight; it sleeps well, is not restless, and its 
whining cry is neither frequent nor prolonged; in the absence of 
gastro-intestinal symptoms, the scanty stools and urine and a sub- 
normal temperature will clinch the diagnosis. 

Holt has drawn attention to the fact that in the early days of the 
disorder there is a rise of temperature to 104° or 105° F. (inanition 
fever), which, however, soon declines if plenty of food is given. Infants 
can be made ill with a perfectly wholesome food if it be given in 
excessive quantity. Overfeeding may mean a superabundance of 
all ingredients or of a single one. It sometimes causes severe and 
persistent indigestion when the infant is fed at irregular or too short 
intervals, or is given too much at a single feeding. 

The baby suffers from colic announced by a sharp piercing cry, 
which often begins at a definite time after feeding and is continued 
until eructation, or vomiting, or the passage of flatus apparently 
brings relief. During the attack the extremities are rather cold, the 
thighs are flexed upon the abdomen, and the latter is rigid, evidently 
due to a circulatory disturbance in the splanchnic area (especially 
of the intestinal walls). Spitting frequently heralds the trouble, 
followed in some cases by vomiting. Generally the infant is cross, 
fretful, runs a slight temperature, and sleeps restlessly. Not infre- 
quently the baby suffers from facial eczema and seborrhea of the 
scalp (often limited to the anterior fontanelle), though other areas 
of the skin may look fresh and pink and show normal elasticity. 



DISTURBANCE OF BALANCE 205 

These disturbances are seen in artificially fed as well as breast-fed 
babies; in the latter a high fat percentage is said to be the etiological 
factor. The condition is serious, principally on account of difficulties 
that may arise during and after weaning. With the artificially fed 
baby nutritional disturbances and their serious consequences most 
commonly result from too large quantities, or too strong modifications 
of milk or too frequent feedings. 

Too much even of a properly modified milk mixture, given at one 
time or at too short intervals, will often retard weight development; 
therefore, the mere fact that a baby does not gain but even loses 
weight is no indication for increasing its amount of food. If other 
causes, such as adenoids, stomatitis, syphilis, and tuberculosis can be 
excluded from the etiology, a decline in the weight curve, in spite of 
a plentiful supply of proper food, strongly indicates disturbed nutri- 
tion. The digestive tract needs rest. If this is prevented by too 
frequent feedings, the stomach is never emptied completely; less 
HC1 is secreted, and is therefore not present in a free state, which 
in turn acts unfavorably on the secretion of the pancreas. 

Ambitious mothers should therefore be warned against the disas- 
trous consequences of excessive feeding; not only does it cause gastro- 
intestinal disturbances and a predisposition to intestinal infection, 
but it may so upset the equilibrium of the metabolic processes that 
it may take weeks or even months to restore the same. The food 
should be increased, not merely to make the infant weigh more, or 
because its restlessness and crying are wrongly interpreted as a sign 
of hunger, but only when steadily declining weight is accompanied by a 
small amount of feces and urine, while the intestines are apparently 
healthy. 

Disturbance of Balance. — A relatively unobjectionable, pure milk, 
given at regular intervals and adapted in quantity and in composition 
to the requirements of the average infant, does not always insure 
good results. While most children thrive upon it, others, after a few 
weeks of comparatively rapid gain, remain stationary or nearly so 
in weight and in physical development. Increasing the quantity or 
the strength of the food does not improve matters; it may even lead 
to an appreciable decrease in weight. 

Curiously enough the baby hardly seems to be ill; the pulse, respira- 
tion, and the temperature, as well as the urine show no serious disturb- 
ance, but the child is restless, peevish, and pale, though apparently 
not in pain. The stools are often fairly regular, but in fully developed 
cases they are rather dry, light in color, and offensive in odor. They 
leave no stain on the diaper, and their relation to litmus is alkaline. 
Evidently, the food is not being assimilated. 

Proteins and carbohydrates do not seem to be the cause of the 
trouble, because a change to a food rich in both but poor in fat, given 
in small quantities at first, usually remedies the trouble. The disturb- 
ance is due to the fat of the cow's milk, only a small percentage of 
which is tolerated, and whenever this limit is exceeded the trouble 



200 NORMAL DIGESTION 

reappears. We emphasize "the fat of cow's milk," on account of the 
remarkable fact that in these cases breast milk is well borne in spite 
of its high fat content. 

Dyspepsia. — In artificially fed infants, even under the most favor- 
able circumstances, the digestive organs must perform an increased 
amount of work, and overfeeding, of course, adds to this burden. 
When combined with an alteration in the osmotic conditions in the 
intestine, it can be readily understood that it might cause a certain 
exhaustion of the digestive and the absorptive capacity. Naturally, 
intermediary metabolism in turn is affected, and the degree of derange- 
ment finds expression in the progressively severe symptoms observed 
in dyspepsia, intoxication, and decomposition. 

The first of these — dyspepsia — often quickly follows a neglected 
condition resulting in loss of weight, but the symptoms vary greatly. 
It represents a very extreme disturbance of nutrition, the term imply- 
ing not merely non-digestion, but rather a disturbed digestion through 
the action of the food or its derivatives. If the digestive processes 
themselves are involved, dyspepsia is not a primary affection, but the 
result of a general condition. 

Thin, delicate infants, especially those under three months old, are 
more susceptible, but even the robust are not immune if serious dietetic 
errors are made. Diarrhea, vomiting, and gas formation dominate 
the clinical picture. The stools are watery, green, and frequent, four 
to six being usually passed within twenty-four hours; they contain 
small curds, consisting, not of undigested proteins, but of fats and 
fat soaps. Vomiting, apparently the result of gastric irritation, 
may occur immediately after feeding or later. The temperature 
exceeds by one or two degrees the daily variation in healthy infants. 
The weight drops distinctly during the first few days, then either 
remains stationary, or declines slowly. 

Symptoms of abnormal fermentation in the gastro-intestinal tract — 
eructations, foamy fecal discharges passed with flatus, colic, and dis- 
tention of the abdomen — are marked the higher the percentage of 
carbohydrates, especially of sugar, in the food; as, for example, in 
condensed milk. The urine is negative as to albumin, sugar, and 
casts, but contains an increased amount of ammonia. The little 
patient does not appear seriously ill, the heart, the lungs, and the 
kidneys seem unaffected, but it is peevish, restless, and often cries 
with pain. 

Here, again, fat is at fault, as to all appearances it lowers the tol- 
erance for sugars, though the latter (in the order of their injuriousness, 
milk sugar, cane sugar, and maltose) are the principal cause of the 
disorder. Sugars and fats probably cause the formation of acids which, 
by withdrawing the alkalies from the system, may produce a relative 
acidosis, as evidenced by the increased ammonia coefficient in the 
urine. If the condition is recognized in time, and either good breast 
milk is given or the fats and sugars are reduced to a minimum, improve- 
ment will most likelv set in. The chief danger lies in the fact that 



A I AMENTA RY INTOXICA TION 207 

the disorder may go on to intoxication and decomposition, which 
would be serious for the weakened child. 

Alimentary Intoxication. — Alimentary intoxication is a severe dis- 
turbance of intermediary metabolism with evidences of relative 
acidosis, a condition resembling diabetes or uremia, which follows 
dyspepsia when the injurious food is continued. It is characterized 
by its sudden onset (there is also a lingering form), diarrhea, vomiting, 
high fever, sugar in the urine, leukocytosis, and eventually collapse. 
On account of its most prominent symptoms, the disease was formerly 
thought to be bacterial in origin, and was classified as acute gastro- 
enteritis, or as cholera infantum. 

It is true, bacterial infection can scarcely be disregarded as an etio- 
logic factor, but is it the chief one? The experience that most of these 
cases, if seen the first day, respond within twenty-four to forty-eight 
hours to starvation treatment certainly does not favor this assump- 
tion; but, on the contrary, points to the food as the primary cause. 
Indeed Finkelstein and Meyer have proved that an excess of milk 
sugar can produce the whole symptom-complex of this intoxication, 
especially if the, food has a high fat percentage. That the disorder 
is not only intestinal but is also connected with metabolism is shown 
by the presence of sugar in the urine. 

There is a possibility that milk decomposed by bacteria before or 
after ingestion may irritate the intestine, and after its absorption 
derange the metabolism. So far, however, the toxic action of these 
products has not been definitely demonstrated, and we have reason 
to believe the primary cause to be a dietetic one, and that the decom- 
position of the food and the presence of pathogenic microorganisms, 
as well as the depressing effect of heat are not unimportant additional 
factors. 

Previous alimentary disorders, a lowered resistance from any cause, 
and artificial feeding in itself, create a tendency to the disturbance. 
The onset is usually sudden, the temperature rises steadily to 104° 
or 105° F., or it may fluctuate, and in the case of collapse it falls sud- 
denly. Vomiting and diarrhea occur early, though the latter is not 
always severe — four or five stools daily — but when they reach ten to 
forty, the sunken fontanelle, the pale skin, and the dry mucous mem- 
branes are symptoms that cannot be mistaken. 

In the milder cases the baby looks sick, the face is pale, expression- 
less, and sleepy-looking, while in the more serious ones the child is 
apathetic, and never smiles. The half-opened eyes, together with a 
pinched expression, a bluish-gray color of the skin, and coma make 
the prognosis doubtful. The more severe the diarrhea, the more 
decided is the loss in weight. After the initial loss (sometimes as 
much as half a pound to two pounds a day) the weight remains 
stationary or declines slowly. The respirations deepen, their rhythm 
is accelerated, and the infant gasps for air. 

On examining the chest signs of hypostatic pneumonia are often 
found. On account of the great loss of fluid no anemia is demon- 



208 NORMAL DIGESTION 

strable, but leukocytosis seems always to be present. The disturbed 
circulation is manifested by the pallor of the skin, cerebral symptoms, 
hypostatic pneumonia, and meteorism, the latter resulting from 
splanchnic congestion. Glycosuria is a constant and early symptom. 
Albumin and casts are found in the urine, but the absence of leukocytes 
and epithelial cells excludes inflammation of the kidneys. 

Decomposition represents the complete failure of the digestion, 
which progressively affects the resources of the organism, and finally 
leads to its complete breakdown. The condition usually follows a 
neglected digestive disorder, repeated attacks of dyspepsia, or a 
toxic condition, and is characterized by nervous irritability, emacia- 
tion, irregular respiration, subnormal temperature, and a slow pulse; 
the urinary findings are normal. The malady is aggravated by taking 
food, and leads rapidly to decomposition of the body. In this advanced 
stage the infant's organism seems to have lost all power of assimilating 
even minute quantities of food. To all appearances, a true reversal 
of nutrition has taken place, and the child has no chance for its life. 

Even in mild cases improvement is tardy. The general state of 
the patient undergoes a radical change, it is nervous, sleeps badly, 
cries for hours at a time, and can only be quieted by the bottle, which 
is taken eagerly; it seems always hungry and thirsty, yet continually 
loses flesh. The weight falls with the progress of the disease, at first 
perhaps only an ounce per day, but the decline is more rapid as decom- 
position advances. The dry, inelastic skin soon hangs in loose folds 
over the bones, the eyes become large and hollow, the lips pale, and 
the skin assumes a grayish-blue hue, giving the child an unsightly, 
ape-like appearance — the horror of the pediatrician. 

The bowel movements vary in character. They may resemble the 
normal or they may be slimy, loose and offensive, or may show all 
the characteristics of soap-stools. The urine, rather large in amount, 
is negative except for indican; sugar and albumin are found only in 
the last stages. The vital forces seem to be slowly ebbing away, 
sometimes interrupted by a short but passing toxic excitation. The 
pulse becomes small, frequent, and gradually falls from 110 to 80, 70, 
or even 60. Deep breathing, sighing respirations, finally assuming 
the Cheyne-Stokes type, and a frequently subnormal temperature, 
possibly now and then interrupted by a sudden rise to be followed by 
a sharp decline, complete the pitiful picture. The gradually increas- 
ing relaxation may end in collapse, or death may occur from terminal 
pneumonia, otitis, etc. 

Every physician knows the picture of atrophy clinically, but the 
theoretical explanation is modern, and merits attention. The decom- 
position affects first the fat, only a small amount of which is tolerated, 
and only for a short time. A limited percentage of carbohydrates 
can be borne with relative impunity, especially if the fats are cut out. 
Casein and albumin also seem to favor the decomposition. 

No other problem of infant feeding shows more clearly the tremen- 
dous advantage of human milk, which is the only salvation for very 



EXAMINATION OF FECES 209 

young -infants. \YJien fed upon it mild cases of decomposition improve 

rapidly, in spite of the fats and carbohydrates, and even severe ones 
have a good chance of recovery under careful management. 

Feces. — Examination of the feces is no more important than 
the observation of the child's weight, the skin, the turgor, and its 
activity; but, in the majority of cases, the first evidence of nutritional 
disturbance is an increased number of bowel movements. First, their 
looseness, then their change in color, later curds, perhaps the presence 
of blood and an excess of fats or of mucus (pus is not often visible) 
attract our attention. 

These changes are significant of a diseased condition, but not neces- 
sarily of any special disease. Almost all of the diseases of infancy 
may be accompanied by diarrhea; this holds true even in certain cases 
of syphilis and tuberculosis. Although the most severe form of 
diarrhea is seen in intestinal intoxication, on the other hand, intoxica- 
tion may cause only a slight diarrhea. 

In studying the feces then, as to their color, consistency, composi- 
tion, odor and bulk, or in comparing them with the normal, we must 
not forget that from time to time even in the healthy infant the 
movements may be more or less watery, or may contain coarse white 
flakes, without any appreciable functional disturbance in the gastro- 
intestinal tract. As mentioned before, small whitish particles in the 
feces of breast-fed infants are not always casein but often are the 
so-called milk-granules of Uffelmann. For the characteristics of 
normal stools we refer to the description on pages 194 and 273. 

The amount of the stool is increased in all disorders of nutrition 
except in starvation which is merely the result of lack of food. In 
acute illness the more numerous the movements and the larger the 
total bulk, the greater the resulting exhaustion. In some chronic 
affections the quantity of the feces discharged may be very large, 
indicating a marked diminution of the child's absorptive powers. 
In this way the baby is starved in spite of its consuming a sufficient 
amount of digestible food. 

After the first few weeks of life the healthy infant has one to three 
passages per day; if artificially fed, even five are not pathological, 
other characteristics being normal. Their number is slightly increased 
in affections of the upper intestine, while in inflammatory processes 
of the colon as many as twenty are not uncommon. 

The reaction of the feces is said to be slightly acid in the breast-fed 
and neutral or alkaline in the bottle-fed baby. Acidity can be demon- 
strated by litmus in cases of fat indigestion (due to fatty acids) and 
of carbohydrate intolerance (due to acetic and lactic acids) ; alkalinity, 
however, may be shown where putrefaction predominates, as in pro- 
tein indigestion. The reaction of the intestinal contents differs in 
different parts of the intestines, and doubtless depends to some extent 
on the kind of food taken. It probably largely determines the variety 
of bacteria flourishing in the gastro-intestinal canal, although the con- 
trary is claimed — that the microorganisms present determine the reaction. 
14 



210 NORMAL DIGESTION 

The color of the stools in morbid conditions varies so greatly from 
the normal that it is impossible to describe all the variations. The 
stools, normally a golden-yellow in the breast-fed, and a lighter 
yellow in bottle-fed babies, become brownish when cereals are added 
to the food. When the solids are much reduced, as in acute and 
copious diarrheas, the discharges may lose all color and look like 
serum, or like water containing white flakes of lymph (the so-called 
rice-water stools). 

Clay-colored stools are abnormal, but do not necessarily indicate 
a serious condition. They are often due to a diminished amount of 
bile (as from biliary obstruction) or to an excess of undigested fat. 
Ashen-colored stools, however, are not always referable to the absence 
of bile or bile salts. A marked decrease in the hydrobilirubin content, 
a reduction product of bilirubin from which the normal feces derive 
their color, produces urobilinogen, a colorless substance normally 
found in the dry whitish stool of fat constipation. Bilirubin when 
oxidized changes into biliverdin, which is supposed to be the cause 
of the so-called green stools so frequently seen in infantile diarrhea. 

Formerly this green color was supposed to be due to the action of 
bacteria, and for a time this assumption seemed to be confirmed by 
the appearance of green stools in institutional bottle-fed infants. 
Sometimes the stools are yellow when passed, but acquire a greenish 
tinge on the surface after exposure to the air. Practically all shades 
of green are observed, owing to the mixture of green, yellow, Avhite, 
and brown. The colored stools in themselves are not significant of 
any particular disease, but merely indicate an abnormal condition. 

Calomel medication often produces green stools, but this color 
disappears as soon as the drug is excreted, and probably indicates 
an excess of biliverdin which is not reabsorbed because of the hurried 
bowel movement. An admixture of blood makes the feces look red 
when they come from the lower part of the bowels and reddish-black 
or tarry from lesions higher up. Iron, bismuth, and manganese taken 
as medicine all make the feces more or less black, the shade depending, 
of course, upon the size of the doses and the intervals between them. 

The odor of the defecations is caused by gases which form under 
the influence of bacteria in the digestive tract. In infants fed entirely 
on breast milk or properly modified cow's milk, the odor is usually 
slight, but it becomes stronger when other articles are added to the 
food; it is supposed to be sour or pungent in acid fermentation 
(favored by carbohydrates), and foul when putrefactive processes 
predominate. The latter are probably not always due to protein 
indigestion, but often to decomposition of intestinal mucus or pus 
which is often present in intestinal irritation. In fat indigestion 
the fecal discharges smell rancid and sour. 

Although these statements cannot be offered as scientifically proved 
facts, they may be helpful in diagnosis and treatment, since they 
indicate the cutting down of carbohydrates in excessive fermentation 
and the reduction of the percentage of proteins in putrefaction. 



COMPOSITION OF FECES 211 

The consistency of the feces depends chiefly upon the water and 
the fat contents. Normal discharges of infants fed on milk are free 
from lumps and are of a butter-like consistency — semisolid. They 
gradually become formed when other kinds of food are taken and 
their passage through the large intestine is delayed. A liquid state is 
just as abnormal as a too solid one. ( Copious watery diarrhea tends to 
dehydrate and to demineralize the system and, therefore, is dan- 
gerous, aside from the fact that absorption must suffer considerably 
if the food is hurried through the gut. Thin and watery stools are 
met with in typhoid fever, in gastro-enteritis, in rectal stricture, and 
often after hydragogue cathartic medication. 

Composition. — In addition to the substances ingested as food, the 
fecal discharges contain bile, mucus, epithelial debris, residues of 
secretions, and many bacteria; in diseased conditions, blood, mem- 
branes, and pus may also be found. A certain amount of mucus is 
normally present in the feces, but as it is mixed it is not very apparent. 
It may be found in excess where there has been prolonged irritation 
by hard scybala as well as in other digestive disturbances; but 
it may be much increased in purely functional conditions, therefore 
is not always indicative of intestinal inflammation. It is discharged 
either in little balls (resulting from peristalsis) from the small intestine, 
or in stringy fragments from the colon, and may make up as much as 
one-third of the fecal mass. 

Excessive fat in the food may cause either large, hard, dry, crumbly 
stools, which do not even soften when a soapsuds enema is given, or 
loose, greasy movements which look like oil. Often such feces are 
sour-smelling, yellow, greenish-yellow, or even green in color, and 
have the curdled appearance of scrambled eggs. Sometimes, however, 
large, gray, putty-like movements of a peculiar ammoniacal odor are 
passed. Very little, if any, protein remnants of the food are found 
in the feces of breast-fed babies, while the stools of bottle-fed babies 
may contain a little more. 

Occasionally undigested fat and balls of mucus are mistaken for 
casein curds; the latter are large, smooth, white or grayish, bean-like 
bodies, and frequently occur in otherwise normal stools. They may 
mean nothing but a simple non-digestion of the casein; in fact, they 
are said to disappear when boiled milk is given and to reappear on 
feeding raw milk. 

Blood is not infrequently seen in the stools in severe intestinal 
conditions, probably more from congestion than ulceration. Hard 
fecal masses are often streaked with bright red blood which comes 
from a small tear in the anal mucous membrane, or occasionally from 
small bleeding polypi. Small, frequent stools of blood and mucus 
only, passed with straining, point strongly to intussusception. In 
melena neonatorum the stools are tarry black. Pus may be seen in 
rare cases of communicating ischiorectal abscess, gonorrheal proctitis, 
or impacted foreign bodies. 



CHAPTER X. 
FRESH AIR IN THE TREATMENT OF DISEASE. 

One must always study all the factors leading up to and, possibly, 
causing disease, and before deciding the positive influence of one 
factor, eliminate wholly or in part other etiological influences. 

In considering, therefore, the role that fresh air plays, " controls" 
should be employed, as far as possible, for the comparison of a series 
of cases of the same type of disease living under similar conditions 
should enable one to draw fairly accurate conclusions. 

My first work in fresh air treatment began some fourteen years 
ago in the children's wards of the Philadelphia Hospital. The wards 
were large, the milk fairly good, enough nurses were on duty to keep 
the children fed according to my directions, they were bathed regularly 
and kept clean; but in the wards where the very young infants, mostly 
foundlings, were placed, the results were very unsatisfactory. Much 
depended upon the physical condition of the infant on admission. 
A frail infant, perhaps premature and under normal weight, would 
gain for a few weeks at best, then remain stationary in weight, finally 
gradually lose weight, begin to have diarrhea and die. Robust infants 
on admission often did well for three months. The same symptoms 
after this period began to develop as in the infants admitted in a con- 
dition of malnutrition *and, in spite of my best efforts, many of these 
robust children died. 

Infants of the same type in my private practice were almost without 
exception doing well. Convinced that neither the food, nursing, nor 
general care of these hospital infants was at fault, and that the so-called 
hospitalism was nothing but lack of fresh air, and lack of outdoor air, 
I ordered these children, in the month of January, placed for two 
hours each day on the fire-escapes. 

The cribs were simply moved out upon the fire-escapes, and towels 
pinned over the top of both ends of the crib, as wind shields. The 
infant mortality began to lessen immediately, and I began to see some 
hope for my infant hospital patients. In the following two or three 
years, during my service in January, February and March of each 
year, I had the children, for a number of hours each day, unless it 
was raining or snowing, carried down to the large open space facing 
the hospital buildings, and kept in small hammocks. These infants 
were always bundled up in blankets, their heads well covered, and ■ 
their eyes, nose and mouth covered with a gauze veil. They did 
remarkably well; so well, in fact, that instead of my infants dying 
most of them began to gain in weight and health, and the deaths were * 
almost entirely in infants under three months of age, whose condition 
was distinctly bad upon admission to the hospital. 



FRESH AIR TN THE TREATMENT OF DISEASE 213 

During the past eleven years the infants have been placed in the 
new modern and up-to-date building of the Philadelphia Hospital. 
The wards are large, the air space ample, the milk the very best; 
porches surround the hospital on two sides, the infants practically 
have an abundance of fresh air day and night, and they do as well 
as could be hoped for. I am no longer a pessimist when in the infants' 
ward, but an optimist. In the new Jefferson Hospital, where I am on 
duty the entire year, the children have an ideal ward on the eighth 
floor, large windows on three sides with a large roof garden adjoining, 
the latter fitted up with every convenience, such as hammocks, shade, 
wind shields, etc. The roof garden is used all the year round, winter 
and summer, and the results are most encouraging. 

Of all the factors which have contributed to the reduction of this 
infant mortality, fresh air has, in my opinion, been the one of prime 
importance. 

During the last nine years in my service in the Philadelphia Hos- 
pital, I have treated all my severe cases of broncho- and lobar pneu- 
monia in children of all ages by the fresh air method. These infants 
and children, as soon as taken ill, are removed from the general ward 
and placed in a special room provided for such cases. The room holds 
six cribs comfortably, and rarely, during my service in the last three 
years, has a bed been vacant. Many of these cases are secondary 
bronchopneumonias. A large percentage of the children, in fact most 
of them, are hospital children, but the results have been so different 
from those following the methods of years ago, that I have lost much of 
my dread of pneumonia as a hospital disease. True, these cases have 
good nursing, good care and every possible attention, but still they 
are cases of pneumonia in hospital practice and they do remarkably well. 

In another similar room in the same hospital, during the same 
period of time, I have been treating my typhoids. Occasionally, 
I have a typhoid under two years of age, most of them are over 
three, and the average age about six years. The typhoid cases come 
from the same class of patients as the pneumonias, and they do so 
much better in the fresh air that nothing could persuade me to return 
to the old method of treatment, similar in every way to the present, 
but minus the fresh air. The rooms where the typhoids and pneu- 
monias are kept have large windows on two sides, and an open door 
on a third side; these are kept open day and night; a distinct effort 
is made to keep the hands and feet of these children warm by gloves, 
stockings and hot-water bags, but the rooms are always cold, except 
for a few minutes every two or three hours, when the windows are 
closed and all the children carefully examined as to cleanliness, etc. 

The few T cases of tuberculosis are kept in a special portion of one 
of the porches, living practically in the open air. Arrangements are 
just being made for a special pavilion for these cases. In the Jefferson 
Hospital the pneumonia and typhoid cases are treated by the fresh 
air method, and do infinitely better than formerly, when the fresh 
air treatment was not employed. 



21-1 FRESH AIR IN THE TREATMENT OF DISEASE 

In private practice for eleven years I have treated all infants and 
children, sick and well, with fresh air; in fact, on my first visit to the 
child, I try to instill into the mother's mind the principle that fresh air 
differs from impure air as much as fresh milk from impure milk. Once 
gain her consent, and the treatment is an assured fact. I am more 
than surprised to see the willingness with which most mothers, no 
matter what their social status may be, enter into the treatment. 
The physician must be enthusiastic; the mother is, in my experience, 
readily convinced. 

During both the winters and the summers of the past eleven years, I 
have kept numerous infants out of doors all day long, except bringing 
them in occasionally to the house for the purpose of removing soiled 
clothing, and I have never in all that time seen a single injurious 
symptom result, and I am positive it has been the means of saving 
many lives. Rickets, scrofulosis, gastro-intestinal disease, any and 
all conditions are benefited by the treatment. Measles, in hospital 
cases, I treat in separate rooms, each room opening upon a common 
porch, surrounded by glass. During the first few days the children 
are kept in the cool, darkened rooms, then moved to cribs on the 
porch; the windows on the porch are opened more or less, insuring 
an abundance of fresh air. The influence of climate associated with 
rest in the treatment of nephritis and cardiac disease is now so well 
recognized that comment is unnecessary. 

It is an interesting question, which experience alone can decide, 
as to what arrangement will, in the future, be made to control the 
degree of temperature in which these children are kept when in the 
fresh air. In hospital practice it has been my custom to keep infants 
under three months for a few days in the cool air of the ward before 
putting them outdoors — the temperature of the ward usually being 
near 60° F. in the cooler months. In private practice, where the 
temperature can be more absolutely controlled for each individual 
case, I gradually but rapidly lower the temperature of the room to 
60° F., then, dressing the child exactly as if it were to be taken out- 
doors, gradually lower the temperature of the room for a few hours 
each day until it approximates the degree of temperature in the fresh 
outside air. Indifferent temperature feels neither warm nor cold 
(Wachenheim) , and is most restful. In children, indifferent tempera- 
ture is above 75° F. in summer in summer clothing, and above 65° 
F. in winter in winter clothing, and varies with age and vitality. 
Temperatures above indifferent are not sedative, but cause a contin- 
uous stimulation that is harmful if prolonged, ending in exhaustion. 
The same author also says, "Young children stand severe cold badly." 
This is not my experience, if by " severe cold" is meant the ordinary 
winter weather in Philadelphia. True it is that these children are 
bundled up from head to foot, lie in a comfortable baby coach, and 
have thick gloves, stockings, veil and perhaps a hot-water bag, but 
they do breathe the cool air, and they all do well. Two or three rainy 
or snowy days will convince any one; the children are kept indoors 
in a warm room and they fuss and cry; out of doors they are quiet. 



FRESH AIR IN THE TREATMENT OP DISEASE 215 

Humidity has an influence by checking pr increasing the evaporation 

from the body, and further studies along thi> lino will be of value. 
The distance above sea level exerts a certain distinct influence upon 

the skin, kidneys and blood, and induces metabolic changes of impor- 
tance. The influence of a few months of cam]) life on growing boys 
is appreciated by every one. "Camp life" is fresh-air treatment. 

When it i> possible to select the kind of fresh air desired, certain 
broad lines may be followed. Increase of heat production, and. 
consequently, an augmented metabolism, are rendered neces>ary by 
cold, dry air of high altitude-. This is proven by the larger amount 
of carbonic acid gas given off by the lungs. It also, as a rule. increa>e> 
the red blood cells during the first few weeks of treatment. High 
altitudes are good for children with incipient tuberculosis or an 
inherited tendency to tuberculo-i>. 

Fresh seashore air is of decided benefit in infants and children con- 
valescing from severe illnesses, especially gastrointestinal in type. 
It is of distinct benefit also in the so-called strumous type. 

Fresh country air is better than fresh city air. Rural districts 
are better than urban; but density of population, such as on. 
often in large cities, does not necessarily imply lack of fresh air. The 
number of people living in a given area may be very large, but if 
they live in comfortable houses, keep the windows open, and live 
under the best hygienic conditions, fresh air can be secured in abun- 
dance, and infants and children do well. If the same number of 
people living in the same area do not have an abundance of fresh air. 
the infants and children do badly. Density of population may have 
much or little to do with fresh air. 

Statistics prove conclusively that in all countries where the mothers 
work in industrial plants, necessitating their absence from home a 
large portion of the day. the infants and children show a much higher 
mortality rate, owing to the fact of their being kept indoors, than 
is found among the children of the same class of people living under 
exactly similar conditions except that the mothers live at home and 
have time to keep their children in the fresh air. 

In Berlin, 1903, Newman investigated 2701 infant deaths. Where 
the families were in one-room dwellings he found 1792 deaths; in 
two-room dwellings. 754 deaths: in three-room dwellings, 122 deaths; 
in larger dwellings, 43 deaths. Can anything prove more conclusively 
than this the power fresh air has to preserve life, or the rapidity with 
which bad or impure air can cause death? Unfortunately for the 
infant and young child, the ignorance of many mothers, the super- 
stitions and traditions of others, and the carelessness of a few. are 
the greatest barriers to the keeping of children in the fresh air. 

Dining the past few years much has been written upon the impor- 
tance of fresh air for very young children, and the subject of fresh 
air as an aid in the treatment of disease is not of recent date. In 
the History of the Medical Society of the State of New York, as 
published in the New York State Journal of Medicine, it is shown 



216 FRESH AIR IN THE TREATMENT OF DISEASE 

that in the early part of the nineteenth century the dangers of dust- 
laden air were recognized; the influence that certain occupations 
exerted upon the etiology of tuberculosis was appreciated, and even 
at that date "cold air" was used in the treatment of typhus fever. 

In one of these essays upon "The Influence of Trades, Professions 
and Occupations in the United States on the Production of Disease," 
the author shows clearly how the crowding together of children in 
the tenement districts produced gastro-intestinal disease and death, 
proving that at this distant period the virtue of fresh air was appre- 
ciated. 

In 1850 to 1860, Dr. Clark treated a very large number of cases of 
typhus fever in Belle vue Hospital by the fresh air method. The 
windows were removed; in winter stoves were placed before the 
open spaces to insure a slight heating of the air, but the patients were 
given the fresh-air treatment, as we understand it in the fullest sense 
today. The results were vastly superior, the death-rate very markedly 
lower than the mortality among the same class of patients in the 
same hospital at the same period in the hands of the other members 
of the staff where fresh air was not used. It is a well-known fact 
that in times of war patients treated in the Tresh air of tents always 
do better than those confined in hospitals. 

The phenomena of child life have often occupied the attention 
of psychologists, and new theories for children are formed every day 
by educators. Theoretically, they are making the super child, soon 
to be the father of the superman. We, however, should be quite con- 
tent if parents could be taught to appreciate the advantages accruing 
to the child from correct feeding, combined with fresh air, and the 
influence they exert upon the mental and physical development of 
the growing child. 

Everyone should be made to understand how important it is for 
the very young to be taught how to stand, lie down, and sit properly, 
and that deep breathing is the proper and only sure way to secure 
full lung expansion. 

Let us all join hands and preach fresh air; vote for open squares, 
endorse roof gardens, have adenoids and tonsils removed, and, if we 
are willing to endorse and work for the fresh air treatment with the 
same zeal and enthusiasm as that with which we have worked for 
fresh and pure milk, our results will be as great a success as has been 
secured by our milk enthusiasts. 



CHAPTER XI. 

DENTITION. 

The views held several decades ago, concerning the part which 
dentition plays as a causative factor, either direct or indirect, in the 
diseases of children, have undergone a radical change, and much 
found in the earlier literature must today be rejected. Many of the 
writers of that period considered the eruption of the milk-teeth to 
be influential in producing nearly all of the diseases which attack 
children. The claim was made that at least 2o per cent, of deaths 
occurring during the first two years of childhood were due to the 
cutting of the temporary teeth. 




Fig. 25. — Inferior maxillary bone of a child one day old; portion of bone removed in 
order to show the dental sacs, a, left half of lower jaw; shows the sacs of the milk- 
teeth, of the first permanent molar, and of the permanent incisor and canine teeth; 
b, shows the first permanent molar, and the sacs of the milk-teeth. 

Old-time theories and superstitions concerning teething still exist 
among the laity, both the well-to-do and the poor, and the physician 
today is often summoned, perhaps too late, to attend children seriously 
ill with gastro-intestinal disorders, or suffering from dangerous ner- 
vous affections, such as convulsions, the parents believing that the 
illness, being "due to teething, is of comparatively little importance. 
It is obviously the duty of every physician to correct this popular 
but erroneous belief in the widespread influence of dentition as a 
direct cause of disease; for, until this is accomplished, hundreds of 
children will annually die from neglected diseases — diarrheal disorders 
especially — many parents believing that mild, or even moderately 
severe, diarrhea during the period of teething is distinctly beneficial. 



218 



DENTITION 



As opposed to the former belief that all infantile disease was due to 
teething, it is interesting to note that some of the most advanced 
clinicians of today emphatically deny that dentition can, in itself, 
set up any distinct morbid condition. Teething, they claim, is simply 
a physiological process that is normal in the human body, and there- 
fore should not be regarded as a pathologic factor. 

Many of these physicians admit that during the period of dentition 
there exists a predisposition to illness, and I am quite in accord with 
this view. After careful investigations, all recent observers agree 




Fig. 26. — The milk-teeth in a child aged about four years, 
are seen in their alveoli. (Cryer.) 



The permanent teeth 



in ascribing few T er and fewer symptoms to dentition; and, from the 
standpoint of both the safety of the patient and the reputation of the 
physician, it is well to examine the child's whole body carefully before 
making a diagnosis of "teething." This is especially important when 
the symptoms are not local, but remote, as it is often difficult, espe- 
cially when no distinct cause other than teething is apparent, to give 
to dentition its proper causative significance. 

Even if the gums are tense and swollen, and no other adequate 
cause can be detected, it is not w T ise to be too hasty in ascribing to 
dentition a positive causative influence; since such cases, after a few 



DENTITION 210 

days, often clearly show their pulmonary, cerebral, or other origin, 
the process of dentition being merely coincident, or, at the most, it 
intensifies the symptoms and does not produce them. 

Dentition occurs in that period of life when physical development 
is most rapid and functional activity highest. The nervous system 
is in a preparatory condition; the follicular apparatus of the intes- 
tines is rapidly developing, and almost all of the organs and tissues 
bf the body are undergoing change. During infancy and early child- 
hood the mucous membranes are especially vulnerable to disease: 
hence the frequency of stomatitis and other digestive and diarrheal 
disorders. 

If we bear in mind that, during this early period of dentition, the 
child is weaned, and is commonly given food more or less unsuited 
to its digestion, the development of diarrhea in its various forms 
seems obvious. In considering the frequency with which dentition 
causes or complicates disease, the attending circumstances must be 
carefully weighed, and cool judgment is necessary. 

The effects of teething are governed largely by the child's physical 
condition. If healthy, children often pass through thi> critical period 
without any symptoms referable to the eruption of the teeth. If 
they are weak, rachitic, or suffering from malnutrition, inherited 
syphilis, scrofula, or a neurotic temperament, either inherited or 
acquired, the period of teething is one of distinct danger, and is often 
accompanied by pyrexia, with heat, swelling, and redness of the gums, 
stomatitis, and gastro-intestinal disorders. 

In delicate children dentition may, and often does, aggravate the 
symptoms of any existing disease, and to a certain extent this is true 
also of breast-fed healthy infants. Where there is a profound con- 
stitutional disease, either inherited or acquired, the disorders which 
appear during teething may be traced to weakened vitality produced 
by disease, and not to the teething per se; for example, children who 
are constitutionally weak, and who, on the slightest febrile irritation 
produced by the erupting teeth, are rendered unable to digest the 
food best suited to their nourishment when well, the fever having 
temporarily weakened their digestive powers. 

As early as the seventh week of intra-uterine life, the beginning 
formation of the milk-teeth can be detected. Fig. 20 represents the 
dental sacs exposed, as they exist in the lower jaw of a child at birth. 
Fig. 27 depicts a part of both jaws of a child about four years old, and 
shows the relation of the temporary and permanent teeth. 

The formation of the hard part of the tooth begins quite early, 
thin caps or shells of dentin being found on all milk-teeth at the end 
of the fourth month of fetal life, when the coating of enamel begins to 
be deposited. It is, therefore, evident, as pointed out by Forcheimer, 
that the process of teething is in great part accomplished before the 
child is born. 

The calcification of the fangs, and the increasing size of the tooth, 
forces the crown toward the mouth, and perforation of the gum 



220 DENTITION 

follows. Many observers claim that other factors are concerned 
in the eruption of the milk-teeth, but the elongation of the fang is 
certainly the chief one. For details as to the development of the 
teeth, and theories concerning the forces that are operative in the 
advance of the crown toward the gum, the reader is referred to works 
on dental surgery. 

The usual time and order of eruption are as follows : The tw r o lower 
central incisors appear at the age of six or seven months; the upper 
central incisors between the seventh and ninth. During the tenth 
month the upper lateral incisors usually erupt, and the lower lateral 
incisors between the eleventh and twelfth. Well-developed breast-fed 
infants usually have cut all of the incisors at the age of one year. 
The four anterior molars appear between the twelfth and sixteenth 
months; the canines from the sixteenth to the twentieth, and the 
entire set of milk-teeth, twenty in all, should have erupted by the 
time the child is two and a half years old. 

These figures represent, however, only average periods, and a 
delay of a month or more in the appearance of the first teeth, or even 
of several months in the appearance of the later ones, may happen in 
the best-developed and most healthy children. The teeth are usually 
cut in groups or pairs, a considerable period intervening between the 
eruption of each group, and the teeth of the low r er jaw, as a rule, pre- 
ceding those of the upper by a few weeks. 

This normal order of eruption often shows variations, and the 
upper incisors may appear first, especially w r hen dentition is delayed. 
The central incisors may follow, instead of preceding the lateral; 
the posterior molars may precede the canines, or the anterior molars 
may even be the first to erupt. Rickets is commonly found in cases 
where the teeth appear irregularly. 

Absorption of the milk-teeth begins at the extremity of the fangs, 
and progresses toward the crown, the teeth disappearing in much the 
same order as they appear. The fangs being absorbed, the crown 
becomes detached either by the advancing permanent tooth or by 
the accidental pressure to which the slightly attached tooth is neces- 
sarily subjected. 

Dentition may be abnormal either in being premature or delayed; 
when premature, it is, in my experience, usually easy. Dentition 
beginning at five months is not uncommon, and, in rare cases, the 
first tooth may appear at sixteen or even fourteen weeks. Henoch 
mentions two cases of premature dentition at six w ? eeks and thirteen 
days respectively ; but such cases are medical curiosities. 

Occasionally one tooth, and even tw T o teeth have been noticed at 
birth. These natal teeth are usually the incisors of the lower jaw, 
and if poorly formed, consisting largely of crown w r ith little or no 
fang, as is generally the case, they should be removed; for, if allowed 
to remain, they are likely to injure the mother's nipple and the frenum 
of the child's tongue. In a case which recently came under my notice, 
such an injury to the mother's breast necessitated the removal of two 



DENTITION 221 

lower natal incisors. Natal teeth, if fairly well formed and firmly 
attached, should certainly not be interfered with, unless they cause 
distinct disturbance or become loose. 

Delayed dentition is, however, quite common, and indicates that 
the physical condition is below par. In this connection it is interest- 
ing to note that acute disease, if not followed by marked and persis- 
tent constitutional symptoms, has little or no effect upon the time when 
the teeth erupt. Artificially fed children, however, usually cut their 
teeth later than the breast-fed, and a delay of one, or even two months, 
is in such children not unusual. Cases in w T hich dentition is delayed 
until the twelfth or sixteenth month are not uncommon, and Jacobi 
reports the case of a boy who had cut no teeth when two years and 
ten months old. 

Imperfections in the enamel and early decay are quite common in 
cases of delayed dentition, and are due to the fact that, the constitu- 
tion being below^ par, the enamel or dentin is imperfectly formed. 
This imperfect formation of enamel and dentin and early decay are 
regarded by Mr. Hutchinson as in some cases due to infantile stoma- 
titis. Retarded dentition is usually, but not necessarily, connected 
with rachitis; and, wdiile delayed dentition points strongly to rickets, 
it must be borne in mind that the two conditions are not always 
associated. 

Children in w r hom dentition is delayed should undergo a thorough 
physical examination to ascertain whether they have any acquired 
or inherited disease. The diet, hygiene, clothing, bathing, and general 
care of the infant should be carefully looked into. For internal treat- 
ment, the two remedies that best promote dentition are cod liver oil 
and iron. All local measures are useless. 

Any influence which rickets may have upon the time of eruption 
depends upon the age at which distinct rachitic symptoms develop. 
If the disease does not manifest itself until the end of the first year, 
the earliest teeth may appear at the normal period, and a long interval, 
during which dentition is arrested, may follow the symptoms of rickets. 
Teeth that appear during the rachitic period are usually deficient 
in enamel, and decay early. 

When dentition is delayed, many of the symptoms usually attributed 
to teething are caused by the associated condition, L e., rachitis, with 
its inevitable malnutrition. In this connection Finlayson says: 
"The diagnosis of teething diverts the mind of every one concerned 
from the vital points of food, air, and hygiene; the processes leading 
up to rickets are largely under control, even in the cases of those who 
are comparatively poor." 

Occasionally the full number of milk-teeth does not appear. This 
may be owing to a family peculiarity, since the influence of heredity 
can often be traced in the history, or it may be the consequence of 
destruction of the tooth-germ. Absence of one or more of the milk- 
teeth apparently has no effect upon the number or appearance of the 
permanent teeth, notwithstanding the fact that teeth more often fail 



222 DENTITION 

to appear in the second than in the first dentition, an excess in the 
number of milk-teeth being more common than a deficiency. An 
extra incisor is probably the most frequent form of this abnormality. 
Cases of multiple dentition, i\ e., the appearance of more than two 
sets of teeth, have been reported. 

Irregularity in the position of the teeth is more common in the 
permanent than in the temporary set, but is usually limited to a slight 
overlapping of the incisors or a twisting of the canines on their axes. 
This malposition is mainly due to a disproportion between the size 
of the jaw and the space required for the developing teeth, the jaw 
usually being undersized. It is claimed that rickets favors this lack 
of development of the maxillary bones. 

By almost continuous pressure upon the upper incisors, thumb- 
sucking may cause a characteristic deformity. Vigilance on the part 
of the mother or nurse, and, if necessary, binding the hand in a splint, 
or wrapping the thumb in a small bandage saturated with some harm- 
less but intensely bitter preparation, will usually correct this injurious 
habit. 

Lip-sucking is another, but less common, cause of depression of 
the lower incisors. It consists in pressing the upper incisors against 
the lower lip and thus forcing the lower lip against the lower 
incisors. 

The teeth may be poorly formed, in that either their structure 
or their actual shape is defective. Deficiency in lime-salts and imper- 
fections in the enamel, as shown by pigment spots, furrows, or pittings, 
are powerful predisposing causes to early decay, which can be averted 
only by cleanliness and watchful care. 

Hutchinson's teeth are characterized by deformity of the upper 
central incisors, the cutting edges of which are notched and crescentic 
in shape, owing to changes in the early formation which are due to 
inherited syphilis. This notched appearance is positively significant 
of inherited syphilis only when found in the permanent teeth; in the 
milk-teeth it often has no special significance. In inherited syphilis 
both sets of teeth may be affected similarly. 

Teeth of poor shape, often showing deep fissures, offer favorable 
sites for the retention of secretions which may rapidly become the 
breeding-ground of countless microorganisms, and thus predispose 
to caries. Imperfections in the structure of the milk-teeth usually 
indicate lowered vitality or a diseased state of the system during 
intra-uterine or early infantile life. 

As regards the role of dentition in producing definite symptoms or 
conditions, it has already been pointed out that the first duty of the 
physician is to examine the child thoroughly in order to determine 
whether the symptoms may not be due to some cause other than 
teething. The family and the personal history of the little patient 
should always be elicited, the latter including such facts as normal or 
difficult delivery, the method of feeding, the age at which dentition 
began, and the history of all preceding diseases. 



DENTITION 223 

Restlessness, peevishness, disturbed sleep, and moderate fever are 
symptoms commonly met with in children during the teething period. 
It will often be impossible, even after the most careful physical exam- 
ination, to account for their occurrence unless we accept dentition 
as a cause; but the fact that these symptoms are much more common 
in weak and sickly infants than in the healthy, and that they do not 
accompany the eruption of every tooth or group of teeth, confirms 
the belief that dentition may occasionally produce such symptoms in 
a healthy child, and very frequently causes them in those whose powers 
of resistance are weakened by acquired disease or hereditary taint. 

Drooling, which is said to precede teething, and to result from reflex 
stimulation of the salivary glands, is, in my opinion, mainly due to 
the normal establishment of the secretion of these glands, and merely 
betokens a stage in the development of the digestive system of which 
the salivary glands constitute an important part. 

Biting of the fingers or of any hard substance that can be carried 
to the mouth is common during dentition, but it is due to the fact 
that an infant naturally carries everything to its mouth rather than 
to pain or tenderness of the gum. It expresses mild uneasiness or 
itching of the gums, not actual pain, since neither pain nor tenderness 
would be relieved by rubbing or biting on hard substances. A healthy 
child is, when awake, almost always in active motion, and the move- 
ments of the muscles of mastication may be, and probably are, often 
but a part of its general muscular activity. 

In a well-developed, healthy baby the gums are of a pale pink 
color, and change little in appearance except that they become dis- 
tinctly elevated as the tooth approaches the surface. Occasionally 
there is considerable redness as well as heat, and in such cases incision 
is followed by a slight oozing of dark-colored blood. It seems quite 
improbable that, in this portion of the gum which lies immediately 
over the advancing tooth, there can be any severe pain, since it is 
usually paler in color than the surrounding similar tissue, or, at most, 
is only occasionally slightly congested. It is much more reasonable 
to believe that if, as is true, the sensitive pulp and bony fang are 
absorbed without pain, the small portion of the gum overlying the 
advancing crown will be similarly disposed of. 

It is claimed that dentition is a common cause of gingivitis and 
catarrhal stomatitis; but these conditions are rarely, if ever, found 
in healthy, breast-fed infants if the oral mucous membrane has been 
kept clean. When, in bottle-fed babies, the care of the bottles and 
nipples and of the mouth of the child, as is pointed out in the chapter 
on Infant Feeding (page 183), has been neglected, gingivitis and 
stomatitis are of common occurrence. They are due, however, not 
to dentition, but to carelessness on the part of the attendants. The 
irritation occasionally produced by the crown of the milk-tooth at 
the time of its detachment may, however, be sufficient, if strict clean- 
liness is not observed, to produce stomatitis or even local ulceration. 

On slight exposure the bronchial mucous membrane of children 



224 DENTITION 

is easily excited to a mild degree of inflammation, and it is a well- 
known fact that between the ages of one and three years bronchial 
and pulmonary diseases are extremely common. Personally, I have 
never been able to trace any connection between these diseases and 
dentition. 

The skin of a child is so delicate and so easily irritated that an 
explanation for various skin affections has naturally been sought in 
dentition, and its etiologic influence sturdily maintained. Lack of 
cleanliness, unsuitable food, digestive disturbances, improperly given 
baths, and too tight clothing, also inherited and acquired disease, are 
all powerful factors in causing skin diseases in children. When these 
causes are carefully considered there can be no reason for ascribing 
cutaneous disease to dentition. 

Enlargement of the submaxillary lymphatic glands is generally 
due either to some local cause in the mouth which is probably the 
result of lack of cleanliness, or to one of the forms of stomatitis. In 
babies who suffer from scrofula, teething may occasionally be an 
exciting factor; but in healthy little ones it rarely causes any marked 
glandular enlargement. 

In children of strumous diathesis, corneal ulceration is occasionally 
met with, especially during the eruption of the upper canines, or when 
the canines become carious. I have never known it to result from 
dentition in a healthy child. Conjunctivitis is said to be one of the 
many results of teething; but careful examination will usually demon- 
strate its dependence upon some other cause; and, as with corneal 
ulcer, I have never seen it in a healthy child when it could be traced 
to dentition. 

The most common, and also the most dangerous, fallacy in regard 
to teething is the belief that during this period of tooth-cutting diarrhea 
is not only harmless, but even beneficial. It is claimed that the secre- 
tory activity of the glandular system of the intestinal tract is greatly 
stimulated, and normal peristaltic action greatly increased, by reflex 
irritation transmitted through the sympathetic nervous system from 
the gums to the vagus. It has also been maintained that diarrhea is 
often excited by the large quantities of saliva swallowed, this secre- 
tion being stimulated by the irritation of the approaching teeth. 

Digestive and diarrheal disorders owe their origin (as is pointed 
out elsewhere in this work) to entirely different causes, and I am 
convinced that diarrhea is never produced in a healthy child by teeth- 
ing alone. When a child suffers with diarrhea, the slight irritation 
occasionally present from teething may, by increasing the fever and 
restlessness, aggravate the existing gastro-intestinal disturbance, but 
is not sufficient to originate this. 

Teething has been regarded by many as a not uncommon cause 
of acute purulent otitis media. Such a conclusion must, however, 
be based upon the supposition that considerable inflammation, sup- 
puration, or dental caries is present. If either one of these conditions 
exists it may cause inflammation of the ear; but, as one rarely finds 



DENTITION 225 

more than a slight redness or hlueness of the gums, it appears most 
unlikely that dentition ean play any important role in the eausation 
of ear disease. In the past, inflammation in the external auditory 
canal has been ascribed to teething, but it is questionable whether 
reflex dental irritation is, in itself, ever sufficient to induce this con- 
dition. 

The opinion that dentition is the most common cause of infantile 
eclampsia has never been disputed until recent years. There is no 
doubt that a considerable number of all cases of convulsions in children 
are reflex in origin, and that extremely slight causes may, in neurotic 
children, bring on eclampsia. It is, however, very doubtful whether 
dentition per se ever causes convulsions in a well-developed, healthy 
child. Certainly no such case has ever come to my notice. 

It has been claimed, too, by prominent clinicians, that dentition 
may, in peculiarly nervous children, predispose to reflex disturbances 
and be the cause of convulsions, but recent investigations show that 
this must be rarely, if ever, the case. Careful study will usually 
disclose some more potent causative factor. 

Caries of the temporary teeth may set in soon after their eruption, 
and is most commonly observed in the poorly nourished and bottle-fed, 
or those whose oral cavity is not kept scrupulously clean. 

Decay proceeds more rapidly in the temporary than in the per- 
manent teeth, often causing severe pain, especially when liquids, 
either hot or cold, are taken into the mouth. Temporary relief is 
usually afforded by plugging the cavity with a small piece of cotton 
saturated with chloroform, laudanum, or oil of cloves. All cavities 
should be filled with an alloy or gutta-percha in order to relieve the 
pain and preserve the teeth until the time when Nature intends them 
to be absorbed. 

Much can be done by cleanliness to preserve the temporary teeth 
from caries, and during early infancy they should be cleansed every 
morning and evening with a soft piece of linen or muslin wet in sterilized 
water. After the teeth have pierced the gum, a soft tooth-brush 
should be used. All tartar formation should be at once removed 
from the teeth by gently rubbing them with a tooth-pick of soft wood 
dipped in powdered pumice stone. 

If we consider teething as a process that rarely produces marked 
symptoms in healthy children, and a factor that, in delicate or sickly 
infants, may and occasionally does indirectly aggravate symptoms 
resulting from the child's condition or some disease, we cannot con- 
sistently believe in any treatment for dentition per se. Proper diet, 
bathing, clothing, sleep, and hygiene for the child, and the prompt 
treatment of any existing disease or morbid condition, constitute 
the treatment of dentition. 

If we believe in the far-reaching effects of dentition as a cause of 

disease, lancing of the gums is naturally a remedial measure of great 

importance. If, on the other hand, we do not believe in this influence 

of dentition in producing disease, lancing is uncalled for, usually does 

15 



22G DENTITION 

no good, and may, by diverting the attention of the physician away 
from the actual cause of the symptoms, do much harm. 

It rarely, if ever, hastens the eruption of the tooth through the gum; 
indeed, through the resulting scar, it probably retards the onward 
progress of the tooth. Occasionally by relieving the congestion in 
the gum overlying the advancing tooth it may be of temporary service, 
owing to the slight loss of blood which follows. The physician who 
carefully examines his patients has little use for the gum lancet. 



CHAPTER XII. 
RICKETS. 

Rickets, or rachitis, is a constitutional disease of early childhood 
caused by disordered nutrition. It is characterized by developmental 
changes in the bones and cartilages which result in typical deformities, 
also by changes in the muscles, ligaments, nervous system, and many 
other parts of the body. 

Etiology. — Rickets is essentially a disease of infancy, therefore 
most commonly seen in children under two years of age. In the 
majority of cases it appears after the sixth month, although it may be 
congenital, and it never occurs after the skeletal development is com- 
plete. The children of the poor in large cities are especially prone to the 
disease, children of the well-to-do being rarely affected, and then only 
lightly, although if these children are fed on proprietary foods, which 
usually contain an excess of carbohydrates and a deficient amount of 
fat and proteins, they may, and often do, show slight or marked 
rachitic changes. Rickets is most uncommon in the country. 

Lack of hygiene is one of the principal causes of the disease, and in 
congenital rickets it is difficult to estimate the hereditary influence 
when both mother and child have been subjected to the same- un- 
hygienic surroundings and lack of proper nutrition. The health of 
the father is not believed to exert any influence upon the occurrence 
of rachitis except in cases of paternal syphilis, tuberculosis, or chronic 
alcoholism. The important predisposing factors which act upon the 
mother during pregnancy are alcoholism, tuberculosis, syphilis, scanty 
nourishment, lactation, and close indoor confinement. 

Faulty nutrition is by far the most potent factor in the production 
of rickets, the disease being especially common in bottle-fed infants. 
Nurslings, as a rule, rarely show more than the milder manifestations 
of the affection, unless lactation is unduly prolonged to eighteen 
months or two years, or the mother again becomes pregnant, or is 
attacked by some chronic wasting disease which impoverishes her 
milk. The diet of artificially fed babies w T ho are rachitic is usually 
too rich in carbohydrates, but poor in fats and proteins; and the 
impoverished milk of many of the women in the tenement districts, 
if analyzed, would be found to have a low protein and fat content. 

Proprietary foods for babies, as a rule, contain an excess of carbo- 
hydrates, but are deficient in fats and proteins, and rachitis is not 
uncommon in those children who during infancy were fed on one or 
another of these preparations, or exclusively on condensed milk. 

It appears, on the whole, that rachitis is more severe and develops 
much more readily when there is a lack of fats and proteins than when 



228 RICKETS 

there is a deficiency in fats alone; also that if, in addition to these 
errors in diet, there is an excess of carbohydrates, rickets is even more 
likely to result. In support of these theories that certain food changes 
are responsible for its development, may be cited in the following 
observations : 

Bland Sutton, experimenting with lion whelps at the London 
Zoological Gardens, showed that if they were weaned early and fed 
entirely on raw meat they soon became rachitic, and that the rachitic 
changes were most marked when an excess of carbohydrates was given. 
If, however, a diet of powdered bones, cod liver oil, and milk was 
substituted, they quickly recovered. Chossat, in 1842, demonstrated 
by animal experimentation that rachitic changes appeared in the bones 
when lime was excluded from the diet. Heitzmann claims that if 
lactic acid is introduced into the food of young animals rickets will 
develop. 

But, even though lactic acid forms a soluble salt when it unites 
with the calcium in the bones, thus eliminating lime from the system, 
this does not explain the various other abnormalities in the bones 
which are observed in rickets. Young animals fed upon a strictly 
vegetable diet also become rachitic, which fact further emphasizes the 
need of sufficient fat for the growing osseous system. 

In all the foregoing experiments, whenever rachitic symptoms and 
signs developed, these could be made to disappear by so altering the 
diet that the fats and proteins were increased and the carbohydrates 
diminished without making any change in the living conditions ; which 
seems to show how much more important is diet than hygiene in the 
etiology of rachitis. Sex has no influence on its occurrence, since boys 
and girls are alike subject to the disease. 

The geographical distribution of the disease has been quite definitely 
worked out; and, although rickets occurs everywhere, it is most 
common in the temperate zones, the majority of cases being observed 
in large cities. It is more prevalent in Great Britain, Germany, 
Russia, and Italy than in the United States, is rare in the tropics, and 
infrequent in Iceland, Greenland, Denmark, and Norway. 

Nationality and race are also important factors in the occurrence 
of rachitis, since the great majority of cases in the United States 
are seen in negroes and Italians. Practically all negro children exhibit 
some signs of rickets, and it is thought that the change of climate from 
a southern to a northern latitude may be largely responsible for this; 
since, on the whole, the diet of the negro does not differ materially 
from that of other races in the large cities, and rickets is uncommon 
in Africa. 

Illnesses, such as chronic gastro-intestinal disorders, may precede 
rickets, and syphilitic children may show rachitic changes; but, aside 
from these influences which so impair the nutrition that the child can- 
not assimilate sufficient fats and proteins for the needs of the body, 
associated diseases have but little bearing upon the production of 
rachitis in children. 



PATHOLOGY 229 

Most cases of rickets are seen during the winter months, which is 
thought to be due to close confinement and lack of exercise at this 
season of the year, especially among the poorer classes. Findlay 
demonstrated in animals that lack of exercise alone will cause rickets, 
even when plenty of fresh air is provided. 

The chief cause of rachitis is now universally recognized to be 
faulty diet; and, although the precise way in which rachitic changes 
are brought about is not clearly understood, there is little doubt that 
the assimilation of calcium salts is in some manner interfered with. 
Mircoli attributes rickets to the action of ordinary pyogenic bacteria 
upon the bones and nervous system. 

Pathology. — In the normal child the bones grow longitudinally by 
the production of bone in the cartilage between the diaphysis and the 
epiphysis, and their thickness is increased by the production of bone 
by the inner layer of the periosteum. In rachitis, however, owing 
either to chronic inflammation or simply to disorders of nutrition, 
this process of growth is altered and becomes abnormal, inasmuch as 
an excess of cartilage is produced, but very little mineral salts are 
deposited, which completely arrests ossification. 

The cells produced by the inner layer of the periosteum also fail to 
ossify, and there is frequently abnormal absorption of the medullary 
layers of bone within the canal. These conditions tend to produce a 
much softer and more vascular bony structure than normal, which, 
owing to the lack of ossification, is very flexible and weak. The bones 
of these children sometimes contain twice as much animal as mineral 
matter, and ossification is so irregular that areas of bone may be 
found scattered throughout the cartilage and the bony parts may be 
infiltrated by islands of cartilage. 

Deformity is most marked in the long bones, because of lack of 
ossification in the external layers of the shaft and increased bone 
absorption in the medullary cavity, which makes the bony shaft very 
thin. The increased proliferation of cells at the epiphysis results in a 
most constant and characteristic change in the form of the bones, 
namely, enlargement of the ends of the long bones, especially notice- 
able at the wrists and ankles, which may be half as large again as 
in normal children. Other characteristic enlargements occur at the 
costal ends of the ribs. 

In addition to these bony changes, pigeon-breast and scoliosis are 
common. The abnormal shape of the softened bones is brought about, 
for the most part, by the weight of the body while the child is in differ- 
ent attitudes, and is most marked if it is allowed to walk, or even to 
sit up unsupported, too soon. In some instances the bones break 
instead of bending, but the fracture is usually of the green-stick 
variety. 

The flat bones of the head and pelvis exhibit changes somewhat 
like those found in other bones of the body. The external surfaces 
are soft, porous, and extremely vascular. At the centres of ossification 
are produced large bosses which are soft and spongy. In other areas 



230 RICKETS 

of the flat bones there may be but a thin membrane in plaee of bony 
structure. When longitudinal section of a large bone is made, the 
epiphyseal junction may be outlined by its bluish color; it is very 
vascular, softer than normal, and reveals attempts at calcification 
nearest the head of the bone. The amount of cartilage at the end of 
each long bone is four or five times greater than normal, and the 
centres of ossification are larger and more vascular than normal. 

On observing a cross-section of the shaft of a long bone, the inner 
layers are found to be quite firm, and most of the decalcification is 
in the external layers of the shaft. The medullary cavity appears to 
be more porous than normal, and more vascular. If a section is made 
through a boss on one of the flat bones, it is found to be soft, spongy, 
and highly vascular, and the ordinary arrangement of the outer and 
inner tables of the skull, separated by the intervening diploe, is lost. 

Aside from the changes in the osseous tissues, there are also certain 
pathological changes in the viscera. Among these enlargement of 
the spleen is, perhaps, the most common, and is the result of hyper- 
plasia of the splenic pulp and follicles. In addition to an increase in the 
connective tissue within the spleen, the capsule is also thickened by a 
fibrous perisplenitis. 

When a section of the spleen is examined microscopically, atrophic 
changes can be detected in the Malpighian bodies, the arterial blood- 
vessel walls show thickening, and the whole organ looks pale and 
anemic. In more than 50 per cent, of children with rickets an enlarged 
spleen can be demonstrated; in exceptional cases it may be more than 
double the normal size. Enlargement of the liver is less frequently 
observed, not being so marked as splenic enlargement, with which it 
may or may not be associated. It is also due to simple hyperplasia 
of the connective tissue. 

There are hyperplastic changes in the lymph nodes of the body 
which render them distinctly palpable; but they do not become as 
large as in syphilis and tuberculosis. The muscles of these children 
show a lack of tonicity, and imperfect and defective striation due to 
lack of nutrition and disuse. 

The microscope reveals in the sectioned muscle excessive nuclei, 
a distortion of the longitudinal striae, and thin imperfect fibers. W T hen 
deformity of the chest is extreme, the lungs are often furrowed by the 
pressure of the deformed ribs; the pressure also causes partial or 
complete atelectasis in these areas, and a compensatory emphysematous 
condition in the adjacent lung tissue. Acute and chronic bronchitis 
and prolonged bronchopneumonia are also common findings in the 
respiratory tract, owing to the general debility from malnutrition. 

The mucosa of the stomach and intestines usually gives evidence of 
more or less chronic catarrhal changes, and a mild degree of dilatation 
not uncommonly results from the atonic condition of the gastric and 
intestinal musculature. Mild hydrocephalus is sometimes observed 
in rachitic children; but the exact relation between these two con- 
ditions is not clear. Hyperplasia of the brain has also been described 



TERMINATION 231 

in connection with rickets, but its relation and significance arc as yet 
undetermined and obscure. 

Histology. — Upon microscopical examination of the end of a long 
bone we see, next to the hyaline cartilage, a layer of proliferating 
cartilage cells and a highly vascular matrix in disordered arrangement. 
Beyond this are columns of hypertrophied cartilage cells in regular 
order, then a zone of calcification, finally a zone of ossification. 

Rachitic changes are most prominent in the layer of proliferating 
cartilage cells and in the columnar area, the proliferating layer being 
thickest in fetal rickets, and the layer of columnar arrangement 
thickest in extra-uterine life. Because of its excessive thickness, the 
epiphysis is compressed and bulges laterally, causing the typical 
rachitic deformity. The increase in cartilage cells and in vascularity, 
which is most marked in the columnar layer, causes the characteristic 
changes in these two zones, while the area of ossification shows deficient 
calcification, and the cartilaginous areas jutting into it make the out- 
line of the zone of ossified cells broad and irregular, instead of narrow 
and sharply defined. 

The periosteum is greatly thickened, much more vascular than nor- 
mal, and strips readily from the bone, revealing beneath it the exces- 
sive cell proliferation which sometimes causes such great thickening 
of the bone that in places the medullary cavity is impinged upon. 
The changes in the flat bones are practically the same as those in the 
long bones, and consist chiefly of increased cell production, increased 
vascularity, and imperfect calcification. 

They are even more pronounced in the spongy bones; and, in 
addition to these changes, the spongy bones contain large medullary 
spaces filled with bloodvessels and cellular connective tissue, and 
occupying the spaces of the eroded bony trabecular. 

Termination. — The rachitic process usually terminates in from three 
months to a year, when ossification sets in, as is evident from the 
appearance of lime salts in the lamella? of the osteoid tissue; in some 
places there is a direct transformation of cartilage into bone. At the 
same time excessive cell proliferation at the epiphysis and on the 
inner surface of the periosteum ceases, and the amount of absorp- 
tion in the medullary cavity decreases, the bones becoming less 
vascular. 

Calcification is accompanied by contraction and condensation of the 
spongy bony structure, so that, on complete recovery, the bones are 
often harder and denser than normal. Tliis shrinkage in the spongy 
bone structure decidedly reduces the degree of deformity from the 
enlarged and prominent epiphyses of the long bones. The bosses on 
the skull become smaller, and the beading of the ribs imperceptible, 
until, finally, all traces of these rachitic changes tend to disappear. 

The curvatures and deformities of the spine, pelvis, and lower 
extremities due to the weight of the thorax are also lessened to some 
degree; but when these deformities have been marked and ossification 
has occurred, permanent signs of rachitis usually remain. 



232 RICKETS 

Symptoms. — The onset of rickets is very gradual. In some cases 
a moderate degree of gastro-intestinal catarrh precedes the actual 
manifestations. Constipation is a common feature, owing to the 
atonic state of the intestinal muscles; but, in some instances, there 
may be alternating attacks of diarrhea as a result of chronic irritation 
of the colon by the hard, dry stools. The appetite is often unimpaired, 
and may even be excessive. Vomiting is uncommon. 

These infants are restless and irritable during the day and sleep 
poorly at night, tossing about in bed and waking at frequent intervals. 
There may be slight fever at the onset of rickets, but any high elevation 
of temperature during the course of the disease should cause the 
physician to suspect some intercurrent infection. Excessive perspira- 
tion about the head and neck, especially at night, is one of the earliest 
and most characteristic symptoms, and is an invariable feature of the 
disease, often continuing for months. This symptom is seldom over- 
looked, since the pillow upon which the rachitic child sleeps is always 
wet, while the rest of the bedclothing is dry. Head rolling is observed 
in many cases, and these children have a habit of grinding their teeth, 
which symptom, however, is not peculiar to rickets alone. 

Chronic catarrhal rhinitis and pharyngitis, attacks of acute and 
chronic bronchitis, and acute colds are common in rachitic children. 
Some observers believe that, in addition to the influence of their lowered 
vitality which would predispose them to such affections of the upper 
respiratory tract, these children also acquire acute colds and bron- 
chitis from sleeping constantly on a wet pillow and lying uncovered 
in bed, the bed-covers being kicked off in their restlessness. 

During the day rachitic children seem languid and indisposed to 
move about, or to be picked up and fondled. This has been attributed 
to tenderness throughout the body, which is sometimes quite marked 
over bony surfaces and certain groups of muscles. 

The general appearance of rachitic children differs somewhat; but, 
as a rule, they are pale and look anemic. Although they frequently 
appear to be well nourished, their flesh is fat and flabby, and their 
muscular tissue has but little tonicity. In exceptional cases of rickets, 
the child's complexion may be very good and the general health 
apparently unimpaired ; in still another class of cases the rachitic child 
may be thin and wasted, presenting the typical picture of marasmus. 

The blood shows no characteristic changes aside from simple anemia. 
The hemoglobin content is low, ranging from 40 to 60 per cent.; 
the number of red cells varies but little from normal. The total number 
of leukocytes is increased, but there is no notable increase of any 
particular variety of white cells. 

The urine presents no characteristic changes which would suggest 
rickets, but the calcium salts may be decreased. Heitzmann claims 
that there is an excess of lactic acid and phosphates in the urine, and 
some observers are inclined to believe that these phosphates are being 
excreted in abnormally large quantities instead of being utilized in 
bone formation. 



EARLY PHYSICAL SIGNS 233 

The mucous membranes of the body are pale and undernourished, 

consequently they readily become inflamed from trivial causes, such as 
slight indiscretions in diet, and moderate changes in the atmosphere 
or climate. This inflammation is apt to pursue a chronic and pro- 
tracted course rather than an acute one. 

Although there are no lesions of the nervous system, yet neurotic 
symptoms are quite common and numerous in rachitis. The view is 
held that these manifestations are simply a result of the impoverished 
condition of the nervous system, in common with all other tissues of 
the body. Rachitic children are all neurotic, and the normal stability 
of the nervous system is retarded until a later age than in the healthy 
child. Baldness at the occiput is often observed in rachitic infants, 
and is due in large measure to the constant tossing of the head to 
and fro upon the pillow. 

Muscular spasms are common, and may take the form of laryngismus 
stridulus, nystagmus, tetany, or convulsions. There is also increased 
susceptibility and response to reflex irritation. Laryngospasm and 
tetany are rarely seen in other than rachitic children, and rickets is 
one of the most common predisposing causes of convulsions. Nervous 
manifestations are most marked in young babies, and the liability to, 
and severity of, the symptoms seem to depend more upon the age 
of the child than upon the severity of the rachitic process. As a result, 
convulsive seizures are most common before the second year, and are 
often excited by gastro-intestinal disturbances, by reflex irritability, 
or by the action of toxins absorbed from the alimentary tract. 

Dentition in rachitic children is usually delayed, and is accompanied 
by gastro-intestinal disturbances, which in large part are due to the 
lowered vitality of the alimentary mucosa; they sometimes prove 
quite serious. The first teeth may be cut at any time from the sixth 
to the eighteenth month, and, although dentition is late, when the 
teeth do erupt, they are well developed and do not decay readily. 
This is in sharp contrast to dentition in syphilitic infants, in whom the 
teeth appear very early, but are poorly developed, and quickly decay. 

Early Physical Signs of Rickets. — The earliest and most typical sign 
of rickets is the rachitic rosary, which is formed by the enlarged and 
widened epiphyses of the ribs at the costochondral junction. The 
nodules, or beads, thus formed are most prominent at the fifth and 
sixth ribs, and it is here that they may be first detected. They can 
practically always be felt by the examining fingers, and in exceptional 
cases are distinctly visible, attaining the size of small marbles. When 
there is marked thoracic deformity, beading is often observed on the 
posterior surface of the anterior chest wall, due to the green-stick 
fractures which take place near the posterior angles of the ribs. The 
ribs in these cases join the cartilage at an angle, instead of end to end, 
and there is partial or complete dislocation of the bony rib backward, 
so that frequently when posterior beading exists there is no beading 
on the external surface of the chest. 

The rachitic rosary can rarely be detected before the third month, 



234 



RICKETS 



and tends to diminish in size under proper treatment or when the 
disease terminates spontaneously, so that there is scarcely a trace of 
these prominences after the fifth year, and they, are not perceptible 
in adults. 

Craniotabes, which is an early rachitic sign, is a softening of the 
cranial bones and the formation of thin spots from pressure within 
the skull as well as from external pressure. It is on the posterior 
portion of the parietal bones and on the occipital bone that most of 
these thin areas are found, for this part of the skull is most frequently 
subjected to pressure w T hen the child is lying down. They are most 




Fig. 27.— Rachitis. 



numerous about the lamboidal suture, seldom appearing on the frontal 
bones in the region of the coronary suture. They are sometimes an 
inch in diameter, and several may be found on the skull at one time. 
To detect them, light pressure should be made upon the skull in 
a direction away from the sutures. When an area is pressed upon, 
a parchment-like crackling sensation is transmitted to the fingers. 
Craniotabes rarely appears in infants who develop rickets after the 
sixth month, and it is much more marked in children who suffer from 
both congenital syphilis and rickets than in those who have congenital 
syphilis alone. 



DEFORMITIES 235 

Rachitic Deformities. — The head of a rachitic child appears to be 
larger than normal; hut this is often due to the diminished size of the 
facial hones, and to the disproportion between the head and the rest 
of the body. In severe eases there may be an actual increase in the 
circumference of the head which is due to abnormally thick cranial 
bones, to cranial bosses, or to hyperostoses. These hyperostoses cause 
a prominence of the frontal and parietal eminences which results in 
the typical square broad forehead. When the bosses are numerous 
they sometimes produce furrows along the line of the coronal, sagittal, 
and frontal sutures, thus forming the hoi-cross-bun type of skull. 

The occiput is flattened by pressure, the crown of the skull is flat 
rather than vaulted, and these flattened surfaces together with the 
square broad forehead give the skull a cuboid rather than a globular 
appearance. The anterior fontanelle is very late in closing, and may 
remain open until the second or third year. 

A faint systolic murmur may sometimes be heard if the ear is placed 
directly over the anterior fontanelle; but this feature is of no diagnostic 
importance, since it is found in other conditions in which the fontanelle 
has failed to close. The closure of the other fontanelles is also delayed, 
and the sutures of the skull may not completely unite until after the 
first or second year. 

The superficial veins of the scalp are enlarged, prominent, and dis- 
tinctly visible. The hair is scant, its growth being retarded, and it is 
worn away from the back and sides of the head by friction and sweat- 
ing. The upper jaw of the rachitic infant is unusually long and 
narrow, while the anterior portion of the lower jaw is broader and 
higher than normal, and curves rather sharply at the site of the canine 
teeth, which gives it a square and angular appearance. 

The Chest. — In addition to the characteristic deformity known as the 
rachitic rosary, the ribs present certain curvatures due to atmospheric 
pressure, one of which is at the junction of the dorsal and lateral 
portions of the thorax, and the other is located anteriorly where the 
ribs curve toward the sternum. A lateral flattening is thus produced, 
which extends from the second rib to the hypochondrium along the 
line of the costochondral articulations. This flattening lessens the 
transverse diameter of the chest and causes the sternum to bulge, thus 
forming the so-called pigeon- or chicken-breast. 

The anteroposterior diameter of the chest is increased. The thorax 
is narrowed at the clavicles, but flares outward below, giving rise to the 
so-called funnel chest. This widening of the costal angle at the tip of 
the sternum is due to the pressure of the liver and spleen. It is most 
marked on the right side owing to the presence of the liver. There is 
also formed at the upper level of the liver, stomach and spleen a 
transverse furrow, known as the rachitic girdle, or Harrisons furrow, 
which is produced by eversion of the lower thorax. It is more apparent 
on inspiration, since this portion of the chest wall does not retract. 

These deformities of the chest are rarely severe in uncomplicated 
cases of rickets, but are exaggerated when the respiration is obstructed 



236 RICKETS 

by enlarged tonsils and adenoids, also in children with chronic bron- 
chitis. In some rachitic children the sternum is depressed instead of 
prominent. 

In mild cases of rickets the spine is normal; but in many well- 
developed rachitic children there is kyphosis in the dorsolumbar region, 
which extends from the middorsal vertebrae to the sacrum. This is 
due not only to the rachitic process in the bodies of the vertebrae, but 
is also induced by the laxness of the vertebral ligaments. It is most 
marked when the child is held in the arms, but can be made to disappear 
if the child is suspended by the feet or laid upon its belly with the legs 
extended. This sign is an important point in the differentiation of 
rickets from Pott's disease. 

Lateral curvature is rare, but when a child under three years of 
age develops this condition it is almost always of rachitic origin. 
Lordosis is also uncommon, but may appear in association with 
deformity of the pelvis. Spinal curvatures and kyphoses of rachitic 
origin which arise during infancy show a tendency to spontaneous 
correction when the supporting ligaments and muscles become normal; 
but when these deformities appear after the third year, accompanied 
by changes in the pelvis, they very often persist throughout life. 

The Pelvis. — The most common pelvic deformity is shortening of the 
anteroposterior diameter and flattening of the pelvis. A thickening 
of the iliac crests also occurs, and many minor changes take place 
which give the pelvis an irregular or crumpled appearance. 

The Extremities. — Deformities of the extremities are usually sym- 
metrical, and are more marked in the lower than in the upper limbs 
because the legs bear the weight of the trunk during the stage in 
which the bones are abnormally soft. The clavicle escapes deformity 
in all except the most severe cases, but it may be rendered quite prom- 
inent by either a green-stick fracture or an increase in the convexity 
of the inner third. The humerus is rarely deformed unless the infant 
is allowed to crawl about too early, when a forward and outward 
curvature often develops. The epiphyses are both enlarged, but not 
as prominent as the enlarged epiphyses of the radius and ulna, the 
distal ends of these two bones of the forearm being very conspicuous, 
and producing that characteristic deformity — the broad wrist. 

The shafts of the radius and ulna may also be curved outward in 
children who use the arms as well as the legs for locomotion, and 
among such children green-stick fractures of these bones are not 
uncommon. Sometimes the radius and ulna become twisted upon 
their longitudinal axes, the radius developing a spiral bend which 
causes pronation of the hands. There are no characteristic deformities 
of the hands; but, in rare cases, there are rachitic enlargements of 
the ends of the metacarpal bones and phalanges which resemble 
syphilitic dactylitis. 

The lower extremities are usually deformed, even in light cases. 
The femur is bent outward and forward by the weight of the child in 
the sitting posture, for these infants rarely attempt to walk or stand 



DIAGNOSIS 23i 

because of pain. Coxa vara may also be produced by the weight of 
the trunk. The tibia and fibula usually curve outward and anteriorly, 
which produces bow-legs, but may in some cases curve inward, so that 
knock-knees result. These are the most common deformities of the 
lower extremities. 

Knock-knees are most frequently seen in girls, and they are believed 
to be caused by an enlargement of the inner condyles of the femurs. 
Bow-legs, in light cases, are due to epiphyseal enlargement, and may 
totally disappear when ossification takes place and the enlarged 
epiphyses shrink and become smaller. In severe cases, bow-legs are 
the result of an outward curvature which is usually associated with 
a more marked anterior curvature, so that the bones are bent forward 
and outward. 

Enlargement of the lower epiphysis of the tibia is quite common, 
and results in the abnormally large ankle so often seen in rachitic 
children; but marked enlargement of the upper epiphyses of the 
tibia and fibula is quite rare and found only in severe cases of rickets. 
In rachitic children fractures of the long bones are usually of the 
green-stick variety, and may be caused by trivial injuries. 

Permanent deformity often results from subperiosteal fractures. 
The bones of the feet are rarely affected, and rachitic flat-foot is quite 
uncommon. The short stature of rachitic children is due to arrested 
growth of the long bones, and is usually exaggerated by the fact that 
the child is bow-legged. 

The Ligaments. — The ligaments of the rachitic child nre relaxed 
and weakened, thus giving but little support to the joints; this in 
large measure accounts for spinal curvatures and other deformities, 
such as knock-knees, overextension of the knee-joint, occasionally 
flat-foot, and abnormal laxity of all the joints of the body. 

The Museles. — In rachitis the muscles are affected in direct pro- 
portion to the damage done the bones. They are hypertonic, undevel- 
oped, and exceedingly flabby. Muscular weakness may be so extreme 
as to make us suspect paralysis. These children are very late in sitting 
upright, standing and walking, because of this lack of muscular tone, 
and the weakened abdominal musculature is largely responsible for 
the protuberant abdomen of the rachitic child. 

Diagnosis. — In well-developed cases the diagnosis of rickets is 
quite easy. Even in its milder form, and early in the course of the 
disease, such symptoms as excessive sweating of the head and neck, 
constipation, restlessness at night, enlarged fontanelles, craniotabes, 
and delayed dentition, are sufficient to warrant a diagnosis of rickets. 
It is this symptom-complex, however, upon which the diagnosis must 
be made, since most of these symptoms, appearing alone, might be 
caused by other diseases. For example, craniotabes occurs in syphilis; 
but the other bony changes in syphilis are found in the shafts of the 
bones, which may even be necrotic, while in rickets the epiphyses 
show the most marked changes, and necrosis never takes place. For 
this reason the .r-rays may be of great value in the differential diag- 



238 RICKETS 

nosis between syphilis and rickets, and in doubtful cases a Wassermann 
test should also be made. 

The rachitic rosary, bowed legs, and epiphyseal enlargements are 
the pathognomonic signs in well-established cases which make a 
rachitic child conspicuous; but, occasionally, cretinism and achondro- 
plasia are mistaken for rickets, or vice, versa. Cretinism can be 
differentiated by the marked mental deficiency, facial expression, 
macroglossia, and the striking disproportion between the height and 
the age of the cretin. Achondroplasia is also distinguished by the 
disproportion between the length of the trunk and of the extremities, 
which is much greater than in rickets, also by the greater softness of 
the bones, which causes, as a rule, more striking deformities. 

The large head of the rachitic child may suggest hydrocephalus; 
but it is cuboid in shape, while the hydrocephalic head is globular. 
Other symptoms and signs of hydrocephalus, such as softening of 
the cranial bones, separating of the fontanelles, and irritability of the 
nervous system, also appear in rickets; but the changes in, and 
deformities of, the long bones so typical of rickets are never seen 
in hydrocephalus, and the rachitic head does not undergo the 
rapidly progressive distention observed in the hydrocephalic child. 

Scurvy may be differentiated from rickets by the acuteness of the 
symptoms and such characteristic signs as spongy gums, ecchymoses 
of the skin, and the tendency to hemorrhage from the mucous mem- 
branes. The extremities in rickets are not nearly as tender as in 
scurvy, and there is practically no pain. Rachitic scoliosis may 
resemble caries of the spine; but, besides the fact that other signs of 
rickets are also to be found, the spine is flexible in early rickets, and 
the curvature may be made to disappear (as stated in the discussion 
of the symptoms) by suspending the child by its feet or laying it down 
upon its belly with the legs extended, while in caries of the vertebrae 
the curvature of the spine is fixed. 

Rachitic coxa vara may be differentiated from congenital dis- 
location of the hip by x-ray examination. Rachitic pseudoparalysis 
which results from weakness of the muscles and ligaments, may be 
mistaken for cerebral palsy or infantile paralysis; but in neither of 
these organic nervous diseases are there any bony deformities such as 
accompany rickets. In cerebral paralysis the reflexes are exaggerated 
and the muscles rigid; in infantile paralysis the reflexes are absent 
and the muscles flaccid; while in rickets the reflexes are normal, and 
the muscles simply exhibit a general weakness due to malnutrition 
and disuse. 

The paralyses caused by acute affections of the brain and spinal 
cord, such as polioencephalitis and myelitis, are characterized by a 
sudden onset, and the paralysis is usually confined to certain groups 
of muscles which show electrical changes; whereas in rickets all the 
muscles of the body are weakened, but there are no symptoms of 
paralysis nor of electrical changes. Postdiphtheritic paralysis may be 
differentiated by the absence of knee-jerks, the various reflexes of the 
body being unaffected in rickets, 



PROPHYLAXIS 239 

Course and Prognosis. — In this affection the prognosis is very favor- 
able as regards life, for rickets is never fatal when uncomplicated, and 
even neglected cases exhibit a tendency to spontaneous recovery 
eventually, although great deformity may remain. If rickets is recog- 
nized early, and properly treated, perfect recovery without deformity 
is the usual outcome. The prognosis as to deformity depends, how- 
ever, not only upon treatment, but also to a certain extent upon the 
severity of the disease in each particular case. 

While the rachitic child is in no danger of dying from rickets, yet 
it is predisposed to intercurrent acute infections because of its lowered 
power of resistance, and these diseases may cause death because of 
the child's want of vitality. Diseases of the respiratory tract, in 
particular, are usually serious in rachitic children on account of the 
abnormal shape of the thorax, while disturbances of the gastrointes- 
tinal tract are stubborn, owing to the poor state of the alimentary 
mucosa. 

The acute symptoms of rickets last, as a rule, for nine to twelve 
months, recovery being gradual. Improvement is shown by a return 
of muscular power, a lessening of the nervous symptoms, and diminu- 
tion of the sweating of the Head. Later the bony changes and con- 
sequent deformities become less prominent. 

Prophylaxis. — The prophylaxis of rickets consists in so regulating 
the diet of every pregnant woman that she is sure to take sufficient 
nourishment during the period of gestation. Strict attention should 
also be paid to the hygienic and living conditions of the expectant 
mother. The same care should be given to the diet and hygiene of 
every nursing mother; for if a healthy mother who has plenty of good 
milk feeds her infant at regular intervals and gives it nothing but 
breast milk, rickets will not develop during the normal period of 
lactation . 

Too frequent feeding should be avoided; once every two hours 
is ample during the first six weeks, after that every two and a half 
hours, and later once every three hours is enough. No preparation 
of patent baby food or condensed milk should be given to supplement 
breast-feeding; too much of barley-water is also harmful; but if the 
mother's milk is deficient in fats and proteins, or in quantity, a for- 
mula of cow's milk, properly prepared, should be given in addition 
to the breast milk. 

Sometimes the quality of the mother's milk is improved by giving 
her tonics, such as the elixir of glycerophosphates, or the compound 
syrup of hypophosphites, in dram doses after meals during the latter 
months of pregnancy and during lactation. 

An infant should never be weaned until it is at least nine months 
old if the mother has any milk, and if there are no contraindications 
to nursing. On the other hand, no child should be permitted to nurse 
after the fourteenth month, at latest. ^When it becomes necessary to 
wean a baby before it is old enough to take undiluted cow's milk, it 
should be placed upon a feeding mixture of diluted cow's milk, modified 



240 RICKETS 

according to its age, weight, and digestive capability. In this way 
it is supplied with the proper amount of fats, proteins, and carbo- 
hydrates. 

Unfortunately, many mothers use proprietary infant foods for 
such children; either because they are more easily prepared, or may 
seem to be cheaper, or because some one has recommended such and 
such a food, or the mothers have seen them advertised. The con- 
tinuous use of these patent foods or of condensed milk as a regular 
diet should be condemned and strictly prohibited, which will largely 
prevent gastro-intestinal disturbances and any likelihood of rickets. 
In addition to modified cow's milk, after the sixth month it is a good 
plan to give artificially fed babies one-half to one ounce of beef juice 
two or three times a week, and a dram or two of orange juice daily. 

Next in importance to diet in the prevention of rickets is attention 
to the hygiene and environment of babies and children. If the sur- 
roundings are clean and sanitary, if the child is given a daily bath, 
if its bowels are opened daily, and if it gets moderate exercise and 
plenty of fresh air, much is done to lessen the susceptibility to rickets. 
The foregoing prophylactic treatment is most essential in the children 
of a family in which there is a predisposition to rickets, and should be 
rigidly carried out. 

Treatment. — The active treatment of rickets consists chiefly in 
regulation of the diet, the hygienic welfare of the rachitic child being 
of secondary importance. The treatment of deformities due to rickets 
needs consideration, but this is usually a problem for the orthopedist. 
In the majority of cases, active rachitic processes are really in progress 
only up to the eighteenth month; therefore it is important that 
rickets be recognized and treated before this time, if deformities are 
to be prevented. Treatment instituted after the second year has but 
little effect, as at this age rachitic changes have already taken place. 

Dietetic Treatment. — When a breast-fed baby becomes rachitic, the 
diet of the mother should be increased both in quantity and quality 
to insure breast milk for the infant which will contain an ample pro- 
portion of fat and proteins. If the milk can not be made richer 
because the mother is not well, either a wet nurse should be secured 
or the breast feedings supplemented by several bottle feedings of a 
properly prepared formula. The infant should not be taken from 
the breast, however, unless the mother's milk can not be sufficiently 
improved to make it agree with the baby, or the mother again becomes 
pregnant. 

If we find that a rachitic infant is being nursed beyond the normal 
period of lactation, it should be promptly weaned, and given food 
suitable to its age and digestive power. Besides increasing the diet 
of the nursing mother whose baby has rickets, her surroundings and 
personal hygiene should receive attention, she should take moderate 
exercise, plenty of rest, and never allow herself to become fatigued. 
In this manner her milk may be so improved both in quantity and 
quality that she can properly nourish the child. 









TREATMENT 241 

Rickets in the artificially fed child should be carefully investigated 
and the diet corrected. If patent foods or condensed milk mixtures 
are being given, these should be stopped immediately, If a formula 
of cow's milk is being used, this should be adjusted, and the feedings 
prepared on a percentage basis that will insure a sufficiency of fat 
and proteins and no excess of carbohydrates. 

If there are evidences of gastric or intestinal indigestion, such as 
anorexia, vomiting, and diarrhea, the bowels should first be swept out 
with one to three drams of castor oil, and a formula given, at first 
very weak, the strength of which can be gradually increased as the 
digestion improves. 

The rachitic infant usually comes under observation when it is 
between twelve and eighteen months old, and at this age its diet 
should be composed of one quart of milk daily with at least an ounce 
of cream (or some other substance rich in animal fat, such as butter), 
also the yolk of an egg, and bread. Later, if the digestion is good, 
a few cereals, such as rice, cream of wheat, or barley may be given 
together with fresh vegetables, such as spinach, peas, beans, or 
asparagus, and a small amount of chicken, fish or mutton. 

This diet is very liberal, and not difficult to follow, the chief object 
being to give an ample supply of fat and to limit the carbohydrates. 
Fresh milk is, perhaps, the most valuable article of food for the rachitic 
child, therefore it should always be taken plentifully at frequent 
intervals throughout the day. Fresh fruit juices and beef juice arc 
very beneficial, and the craving for salt which these children often 
exhibit is an indication of their need for it, which should be satisfied. 

Cod-liver oil is to be regarded as a form of nourishment for rachitic 
children, and should be given in every case unless it causes gastro- 
intestinal disturbances, in which circumstance it should not be used 
during extremely hot weather. Children under one year of age may 
be given one or two drams, divided in three doses, during the day; 
older children may take one dram three times daily, or even more 
than this if the stomach tolerates it, and it can be assimilated. Olive 
oil is, perhaps, not as valuable as cod-liver oil, for these children seem 
to require animal fats; but it may be given in the same dosage, or even 
in larger quantities, since it is not so harmful to the digestion. 

Hygienic Treatment. — Rachitic children should be kept out of doors 
as much as possible, and the rooms in which they sleep should get 
plenty of sunlight and fresh air. The homes of these children should 
be clean, sanitary, and afford plenty of ventilation; but, unfor- 
tunately, such living conditions are hard to procure, since cases of 
rickets usually develop in the large cities; therefore it is wise to send 
such children to the seashore or country. The seashore is, perhaps, 
preferable because of its stimulating effect on the appetite and 
metabolism. 

Care of the skin should not be overlooked, and a daily bath at the 
temperature of the body should be given. Inunctions of olive oil 
are not advisable because the}' interfere with the secretory function 
16 



242 RICKETS 

of the skin. Cold baths are harmful during infancy; but a brine 
bath made by adding one ounce of sea salt to two gallons of water 
is very beneficial, given each morning, and followed by a brisk massage 
or rub. Exercise is absolutely essential to improve the muscular 
tonicity, and should be encouraged in so far as it does not increase 
deformities; for instance, no attempt at walking should be permitted 
while the bones are soft, as the legs will become bowed by the weight 
of the trunk. 

Drug Treatment. — It is difficult to estimate the value of drugs in 
the treatment of rickets inasmuch as there is a tendency to recovery 
under proper dietetic and hygienic care. There are no specifics for 
the cure of the disease, hence tonics and preparations for special 
symptoms meet all the indications. Owing to the nature of the 
rachitic process in the bones, it is advisable to give hypophosphites 
of lime and soda, in combination with cod-liver oil, each teaspoonful 
of the oil containing one-half to one grain each of sodium hypophos- 
phite and of calcium hypophosphite. Lime should always be given, 
preferably in the form of the glycerophosphates or the lactophosphates, 
dose one to five grains, three times a day. The elixir of glycerophos- 
phates has proven of value in rickets because of its tonic effect, and 
may be given in 10- to 30-drop doses. 

There is great diversity of opinion and much discussion as to the 
value of phosphorus in rickets; but it should always be administered, 
since experiments have proven that the giving of phosphorus to young 
animals in suitable dosage is followed by an increased activity of the 
processes in the epiphyseal ossification zone. The one possible objec- 
tion to it is that it may set up gastro-intestinal disturbances; but, if 
the digestion is not already deranged, it may be given in 2T0- to tto 
of a grain doses, three times a day, either in the form of the official 
oil, which may be combined with olive or cod-liver oil, or as Thomp- 
son's solution, which contains -%t of a grain of phosphorus to the 
dram. 

It is claimed by some clinicians that better results are obtained 
when phosphorus is combined with cod liver oil. Other authorities 
maintain that the effect of the phosphorus is negligible, and that 
the benefit derived from this combination is due solely to the cod- 
liver oil. Phosphorus is certainly of little or no value in the later 
stages of rickets, the most favorable time for its administration being 
early in the disease. It is especially beneficial in the cases accompanied 
by craniotabes. 

Owing to the anemia present in rachitic children, iron is always 
indicated, and may be administered in several forms. The syrup of 
ferrous iodide is well borne by most children in 5- to 10-grain doses 
after each meal, or the hypophosphite of iron may be given in 1- to 
5-grain doses, three times a day. Tincture of ferric chloride should 
be administered only to those children who show no gastro-intestinal 
disturbance, and then cautiously in 1- to 3-drop doses, but the sac- 
charated carbonate of iron is very easily borne by the stomach, and 
may be taken in 1- to 3-grain doses. 



TREATMENT OF COMPLICATIONS 243 

Fowler's solution, 1 to 3 drops, is occasionally administered for its 
tonic effect, and the dose may be gradually increased. Glandular 
extracts have been employed with good results in some cases, but 
their use in rickets is not universal. Thyroid extract, in ^-grain doses, 
may be given twice or three times daily with one of the iron prepara- 
tions, preferably the saccharated carbonate. The pituitary gland has 
also been used. 

Of the drugs indicated for special symptoms, atropine sulphate in 
sio of a grain dose, three times a day, may be recommended for the 
relief of the profuse sweating of the head. The bowels may be kept 
regular by the administration of aromatic fluidextract of cascara 
sagrada in 15- to 30-drop doses when necessary, or milk of magnesia 
in \- to 2 -dram doses as required. If the digestion is poor, an effort 
should be made to improve it by giving tincture of mix vomica in 
1- to 3-drop doses combined with dilute hydrochloric acid, drops 1 
to 3, before meals, or by giving quinine sulphate in \- to i-grain doses 
three times a day. 

It is also a good plan to give these children occasionally \ to 1 grain 
of hydrargyrum cum creta, and thoroughly to cleanse the bowels once 
or twice a month with a purgative dose of castor oil ( 1 dram to \ 
ounce). If there is a tendency to convulsions, sodium bromide should 
be given in 2- to 5-grain doses, three times a day. 

Treatment of Complications. — Bronchitis and bronchopneumonia 
are the two most common complications referable to the respiratory 
tract, and call for the usual treatment; but antirachitic remedies are 
more effective than any special measures which can be employed. 
Disturbances of the alimentary tract are by far the most frequent 
complications, and must be treated in the usual way. In acute attacks 
with diarrhea, an initial dose of castor oil, 1 to 2 drams, should be 
given, followed after ten hours by bismuth subnitrate in 10- to 20-grain 
doses, three or four times daily. The diet should be considerably 
restricted for several days. But the treatment of the constitutional 
disease is of the utmost importance, and should always be carried 
out. 

Convulsions form the most common nervous manifestation of 
rickets. Immediate treatment consists in placing the child in a tub 
of water at 100° to 106° F. for three or four minutes, after which it 
should be dried quickly and put into bed. Another effective measure 
is to wrap the child for five to ten minutes in a blanket wrung out 
of hot water, and then wrap it up in a hot dry blanket. If these 
measures do not stop the convulsions, from 5 to 15 grains of potas- 
sium bromide with 2 to 5 grains of chloral hydrate may be injected 
into the rectum. Morphine sulphate, grain -^ to -^, may be given 
hypodermieally in severe cases, or inhalations of chloroform may be 
tried. An enema of warm salt solution or soapsuds should always be 
given, and may in itself afford relief. 

Laryngismus stridulus, a less frequent complication of rickets, is 
due to a neurotic spasm of the vocal cords. It should be treated 



244 RICKETS 

by the use of a hot pack and an enema, or 1 to 2 drams of castor oil. 
If there is a tendency to nocturnal attacks, potassium bromide, 5 
to 15 grains, and chloral hydrate, 2 to 4 grains, should be given each 
evening. 

In tetany, a rare complication of rickets, there is a painful spasm 
of the muscles of the hands and feet. It requires but little special 
treatment, although it is advisable to use a belly band, and to wrap 
the arms and legs in cotton-wool during an attack. The nervous 
manifestations of rickets, in common with complications in various 
parts of the body, call for the recognition of the primary disease 
and its efficient treatment before a permanent cure can be expected. 

Treatment of Deformities. — The prevention of deformities is a very 
essential part of the management of a case of rickets, and consists 
in limiting motion during that period of the disease when the bones 
are soft. The child who shows a tendency to curvature of the spine 
should be kept in the recumbent posture and not allowed to sit up 
unsupported. 

If kyphosis appears, it should be treated by placing the child on a 
Bradford frame or a hard bed, and keeping it in the recumbent posture. 
In severe cases it is advisable to correct the deformity each day by 
turning the child upon its abdomen, and raising the buttocks while 
pressure is made upon the spine. Plaster casts should only be used 
in selected and severe cases, for they interfere with respiration, and 
increase the tendency to bronchitis and bronchopneumonia. When 
there is pelvic deformity, the sitting posture must be avoided, espe- 
cially in girls. Bow-legs and knock-knees can be largely prevented by 
keeping children off their feet until the bones harden and the rachitic 
changes have passed away. Creeping also should be prohibited while 
the bones of the arms are soft. If bowing occurs, properly fitting 
braces should be worn continuously, and walking discouraged. If the 
child curls up its legs in bed, external splints should be applied. 

Intelligent manipulation of the deformed extremities, if done 
early, may reduce the curvatures somewhat; but, after the third year, 
correction of deformities by braces or manipulation is impossible. 
Massage is useful in strengthening the weakened muscles, and may 
to a certain extent inhibit the progress of deformity; but it should 
be performed carefully and judiciously. 

Osteotomy for the correction of deformities should be postponed 
until after the seventh or eighth year, because many rachitic curva- 
tures lessen considerably by this time, and also because there is 
danger that more or less curvature may follow such an operation if 
it be done too early. 

In very young infants curvatures of the extremities have been 
absolutely corrected by the use of a plaster-of-Paris cast. The fore- 
going treatment of deformities from rickets is largely a problem for 
the orthopedist, and it is always advisable to consult one in order to 
secure the best results. 



ACUTE TUCKETS 245 

CONGENITAL RICKETS. 

This form of rickets is seldom encountered in the United States, 
but a few scattered cases have been reported. It arises during intra- 
uterine life when the fetus is deriving its sustenance through the 
placental circulation, and is due to malnutrition and chronic disease 
in the pregnant mother. These infants exhibit at birth the character- 
istic rachitic changes and deformities, the histological changes in the 
bony tissue being to a certain extent the same as in older children. 
The congenital form of rickets is rarely severe, but the rachitic rosary, 
epiphyseal enlargements, and craniotabes may be apparent in these 
children at birth. 

ADOLESCENT, OR LATE, RICKETS. 

This form, also, is rare in America, but not extremely uncommon 
in Europe. It is said to occur more often in girls than in boys, and 
may appear at any time between the sixth year and puberty, or even 
later. In these cases there are both beading of the ribs and epiphyseal 
enlargement, but the skull is normal, since ossification of the cranial 
bones is complete before the onset of the disease. Among the 
deformities caused by late rickets may be mentioned bow-legs, knock- 
knees, flat-foot, femoral curves, coxa vara, and scoliosis. 

ACUTE RICKETS. 

Although cases of acute rickets have been described, rachitic changes 
are essentially chronic, and the existence of an acute form of this 
disease is extremely doubtful. Most cases of so-called " acute 
rickets," if investigated thoroughly, will prove to be scurvy or some 
other disease of similar nature. 



CHAPTER XIII. 

DISEASES OF THE GASTROINTESTINAL TRACT. 

■ 

In the consideration of the diseases of children, affections of the 
gastro-intestinal tract are undoubtedly the most important, for they 
form the basis of many of the illnesses of infancy, and constitute a 
large proportion of the disorders which occur between infancy and 
puberty. Several factors may explain the preponderance of gastro- 
intestinal disturbances over those of other systems of the body which 
are called upon to functionate after birth. 

One of the most significant reasons why the digestive tract so often 
breaks down under the strain is that, of all the systems of the body, 
this alone must utilize material foreign to the body. The circulatory 
system is furnished with a full quota of blood at birth; from birth 
onward the air utilized by the respiratory system varies only slightly 
in composition; but even in the breast-fed infant, and vastly more so 
in the one artificially fed, the digestive system must use material which 
constantly varies in strength and amount. 

Under proper conditions, the digestive apparatus after birth is 
capable of digesting and assimilating the normal food with reasonable 
variations for the individual at every period of life; therefore the true 
explanation of gastro-intestinal affections encountered in infancy and 
childhood lies, not in the inability of the child to assimilate its food, 
but in the failure of the parents to appreciate certain peculiarities, 
both in structure and function, of the digestive system of the infant 
or child, as compared with the adult, which in most instances leads to 
overtaxation of the gastro-intestinal tract by the introduction of 
food unsuitable as to quantity or quality. 



DISEASES OF THE LIPS. 



HERPES. 



Herpes labialis is quite a common affection in children, and receives 
its synonym "fever blister" because it is frequently associated with 
a rise in temperature. It is often seen in pneumonia, but rarely occurs 
in typhoid fever, and the appearance of herpes in a febrile case where 
typhoid is suspected is of no little significance in discriminating against 
that disease. The blisters are of little importance except for the fact 



PERLECHE • 247 

that, after the crust forms, healing is soinetimes greatly retarded by 
the habit of picking the sores which children will persist in, unless 
prevented in some way from reaching them. If this can be done, 
and they are dusted with either boric acid or zinc oxide, they will 
disappear in the course of a few days. 

PERLECHE. 

Perleche is a cracking and ulceration of flic mucous membrane of 
the lips, usually occurring at the angles of the mouth, and affecting 
the vermilion border of the mucous membrane. It is infectious in 
nature, but not syphilitic. 

Etiology. — Perleche is usually observed in children who are in poor 
physical condition, and present other signs of malnutrition, such as 
anemia, chronic nasopharyngitis, adenitis, or scrofula. It is occa- 
sionally observed before the second year, but is most common after 
the period of infancy. The infection is usually conveyed through 
some tiny fissure in the lip, and manifests itself by swelling and 
hyperemia, accompanied by smarting and itching which cause the 
child constantly to lick the corners of the mouth. The tiny fissure 
which was the port of entry of the infection becomes larger, and other 
cracks and fissures appear as a result of the constant irritation pro- 
duced by the tongue. A grayish-white ulcer forms at the angle of 
the mouth; this is composed of macerated, thickened, and opaque 
mucous membrane which closely simulates a syphilitic mucous patch. 
The condition, if not relieved, may persist for several weeks, and in 
some instances constitutes a grave menace to the health of an already 
anemic child, for movements of the lips may be so painful as to make 
the little one refuse its food. The erosions are linear in shape, and 
involve both corners, where the rhagades may be seen slightly elevated 
with a reddened base. 

Diagnosis. — The diagnosis of perleche cannot be clearly made 
without considering syphilitic rhagade, eczema of the lips, and herpes 
labialis. Absence of induration at the base, and of mucous patches 
inside the mouth, strongly indicates perleche. Eczema of the lips 
is usually associated with lesions in other parts of the body, and 
responds much more readily to treatment than perleche. The severity 
of the infection in perleche, and the pain and smarting present, will 
generally exclude herpes. 

Treatment. — The usual duration of perleche is from two to three 
weeks, but it should always be treated since it may become chronic 
if neglected. The best application is silver nitrate, 10 per cent, solu- 
tion, followed daily by a dusting powder of zinc oxide, or the applica- 
tion of boric acid ointment to the raw surface of the lips. Excellent 
results are obtained by the use of an ointment of the red oxide of 
mercury. 

Another mode of treatment which has often proven beneficial, 
although not as quickly effective as those above outlined, is to bathe 



248 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

the corners of the mouth in a 1 to 2000 bichloride solution, fol- 
lowing this immediately and every three hours thereafter by the 
application of ichthyol, 25 per cent. 



DISEASES OF THE TONGUE. 

GEOGRAPHICAL TONGUE. 

Epithelial desquamation of the dorsum of the tongue is a common 
affection in children, and is caused by a chronic superficial desquamat- 
ing glossitis which denudes the tongue of areas of epithelium and 
gives it a so-called "geographical" aspect, because of the irregular, 
round, and crescent-shaped patches it presents. These areas are 
very variable in size, and may coalesce or diminish until they disap- 
pear, or suddenly grow again with great rapidity. The denuded 
patches are red and smooth, the papilla? being absent, the margins 
are grayish or whitish, but the remainder of the surface of the tongue 
is normal. 

The cause of geographical tongue is unknown. It is observed in 
rich and poor children alike, and is apparentlv uninfluenced by hygienic 
care of the mouth. Once observed in a child it will be found to recur 
at varying intervals until adolescence, when it tends to disappear. 
In itself, the condition is of no significance, except that it is often 
mistaken as a symptom of some other disease. No form of treatment 
has as yet proven effective, so that spontaneous cure is the ultimate 
outcome. Most of the cases which have come under my observation 
occurred in rather weak and debilitated children, but improvement 
in their general physical health failed to influence the local condition. 

GLOSSITIS. 

This affection is very rare during childhood, but is occasionally 
seen as a result of accidental trauma from biting the tongue in a fall, 
rage, or convulsion. Now and then glossitis is caused by a strong 
alkali or acid taken by mistake, or by the sting of an insect or a burn. 
Infection and inflammation of the tongue are always followed by 
enlargement of the organ, and much pain. If the infection be severe, 
the tongue may become so large as to protrude from the mouth 
and also interfere with respiration and deglutition. Recovery, usually 
takes place within a few days; but mechanical obstruction from 
enlargement of the organ often greatly alarms the parents, and may 
require urgent measures for relief. 

Treatment. — The child's nourishment should be kept up; and, if 
swallowing is extremely painful, liquids should be introduced by 
means of a catheter through the nose. When the symptoms are most 



ALVEOLAR ABSCESS 249 

acute, ice applied to the under surface of the lower jaw, and kept in 
the mouth continually, will help to relieve the pain. If the swelling 

becomes extreme multiple punctures may be made, or the dorsum of 
the tongue may be scarified on either side of the raphse. 

MICROGLOSSIA. 

Microglossia is a very rare condition in which, owing to an arrest 
in development, the tongue is much smaller than normal. The cause 
of microglossia is unknown, and since the diminutive tongue causes 
little or no disturbance in talking or feeding, the condition is of little 
importance except as a contrast with the opposite condition, macro- 
glossia, which, though rare, occurs with greater frequency. 

MACROGLOSSIA. 

Enlargement of the tongue may be due to an overgrowth of the 
lymphogenous structure (lymphangioma or cavernous macroglossia >, 
to an increase in the muscular and connective tissue elements (fibrinous 
macroglossia), and in some instances to an excess of both lymphogenous 
and connective tissue elements. Occasionally an abnormally long 
tongue is rendered very mobile by an unusually lax frenum, which 
makes it possible for the child to swallow its tongue; several cases 
of this kind are recorded in literature. Aside from this accident, the 
tongue may become so large as to fill up the entire mouth, and prevent 
nursing or the taking of food, or may even protrude from the mouth, 
which causes it to become bruised and chapped, and the inflammation 
results in further enlargement. 

True macroglossia, which is a congenital condition, should never 
be confused with the enlarged tongue of the cretin, familiar to all, 
in whom the tongue is of a deep bluish color, and shows marks of 
the teeth, is prolapsed, and slightly protrudes from the mouth. 

Treatment. — An excessive degree of true hypertrophy of the tongue, 
resulting in interference with the taking of food, calls for the surgical 
removal of a wedge-shaped piece of the organ to prevent death from 
starvation. The cretin's tongue, no matter how large, can always 
be reduced by the proper administration of thyroid gland, and the 
tongue with a mild degree of macroglossia is usually accommodated 
by the natural increase in size of the oral cavitv. 



DISEASES OF THE MOUTH. 

ALVEOLAR ABSCESS. 

Many children are allowed to reach the age of eight or ten years 
before the practice of brushing the teeth is insisted upon, and, as a 



250 DISEASES OF THE GASTRO-INTESTINAL TRACT 

result, caries of the teeth is very common during childhood. Caries 
is followed by infection and inflammation, perhaps by an abscess at 
the root of the tooth which causes great pain and swelling of the 
face and jaw. The breath becomes foul. In addition to local signs 
and symptoms, there are often disturbances of digestion and slight 
fever from inability to masticate the food properly. 

Treatment. — Relief of pain is usually the immediate indication, 
and this may be met by the application of hot poultices externally 
over the affected jaw, and by painting the gums hourly with equal 
parts of tincture of iodin and tincture of opium. If fluctuation can 
be detected the gums should be incised, as, if allowed to remain 
unopened, the abscess usually breaks, and the pus is evacuated into 
the mouth. In some instances these abscesses have been known to 
rupture into the nose, antrum, or maxillary sinus. . 

Upon the detection of inflammation at the root, the best treatment 
by far is immediate extraction of the tooth, which relieves the con- 
dition at once. Following the evacuation of the pus, an antiseptic 
mouth wash should be employed for several days, for which pur- 
pose 20 per cent, hydrogen peroxide or 25 per cent, liquor alkalinus 
antisepticus will prove very efficacious. 

ULCER OF THE FRENUM. 

Ulceration of the frenum of the tongue is usually observed in weak 
infants, or as the result of whooping-cough. The ulcer is caused by 
the contact of the central incisors with the frenum during the act of 
coughing, this producing a shallow, clean-cut, sharp-edged ulcer on 
either side of the frenum. It is most frequently seen in children 
between one and two years of age, and occurs in younger children 
only after they have cut their central incisors. 

Treatment. — The ulcers generally tend to heal spontaneously in 
the course of a week or ten days; but healing is considerably more 
rapid if a 2 per cent, solution of silver nitrate is applied daily to the 
ulcerated areas. 

BEDNAR'S APHTHA. 

Bednar's aphthae is a symmetrical ulceration which occurs on each 
side of the palatine ridge over the hamular process of the palate bone, 
usually in very young infants, and most commonly between the 
second and third months. It is practicallv always due to traumatism 
from too vigorous cleansing of the mouth, which produces abrasions 
of the mucous membrane. At this particular point these abrasions 
quickly become ulcers because of the poor local circulation and the 
tense condition of the mucous membrane. Bednar's aphthae has been 
known to follow thrush, and may also be caused by the use of an 
improperly shaped nipple, but is never due to syphilis. 

Symptoms. — The lesions are oval and shallow, usually bean-shaped, 
and are covered with a grayish necrotic membrane which is very 



CATARRHAL STOMATITIS 251 

adherent, and, if removed, reveals a smooth, reddened base. Nursing 
is so painful that the infant may take the breast for only a few minutes 
at a time or refuse to nurse at all. 

Treatment. — These uleers should be prevented by cleansing the 

mouth with the greatest care in order to avoid bruising the mucous 
membrane, and if a badly shaped artificial nipple is used it should 
be changed and a proper one substituted. The ulcers should be 
touched daily with a 10 per cent, silver nitrate solution, and the mouth 
must be kept clean by following each feeding with a tablespoonful 
of water. In an ordinary case of Bednar's aphthae the ulcers usually 
heal up in the course of a few days. 

CATARRHAL STOMATITIS. 

Catarrhal stomatitis is an extensive inflammation of the mucous 
membrane of the mouth, occurring usually during the first two years 
of life. As a rule, it is due to local irritation from too vigorous cleans- 
ing of the mouth, but it is also seen in association with thrush, 
occasionally during dentition, and in acute contagious diseases. 

Symptoms. — The inflammation is at first usually localized in some 
particular area of the oral mucous membrane, but shows a tendency 
to spread and involve the whole mouth. The inflamed area is intensely 
engorged, reddened, and sharply demarcated from the surrounding 
mucous membrane. As the disease increases in severity the gums 
become swollen, the tongue is coated, and, although there is an 
increased secretion of saliva, the mucous membrane of the mouth is 
hot and dry. Tiny, white, raised dots stud the mouth, tongue, and 
gums, representing the muciparous follicles, with here and there a 
patch, grayish- white in color, overlying an affected area of the surface 
of the mouth. Pain may be so great as to cause the child to refuse its 
nourishment, and become ill and fretful for a few days with a slight 
fever; but, as a rule, there are no constitutional disturbances. In 
some instances the submaxillary glands become enlarged; but the 
inflammation is rarely severe, and there is never tissue necrosis or 
ulceration. 

Prognosis. — In healthy children this is very favorable, the inflam- 
mation disappearing within a few days under proper treatment. 
Delicate children may become seriously ill from lack of nourishment 
and gastro-intestinal disturbances, but usually recover in ten days 
or two weeks. 

Treatment. — Cleanliness of the mouth is of more practical value in 
the treatment of stomatitis than any other procedure. The mouth 
should be washed out after each feeding with a solution of sodium 
bicarbonate and sodium borate, using fifteen grains of each to the 
ounce of water; or, if preferable, a 25 per cent, solution of liquor 
alkalinus antisepticus may be used, usually with prompt and satis- 
factory results. If the inflammation tends to persist, the mouth may 
be swabbed with silver nitrate solution, 0.5 per cent., followed by a 



252 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

mouth wash of cold water, and a pinch of boric acid or alum dusted 
on the tongue. If the mucous membranes of the nostrils and con- 
junctiva are also inflamed, they should be irrigated with the same 
alkaline washes as are used for the mouth. The child's nutrition must 
be kept up by full feeding, using gavage if necessary, and a child of 
one year should always be given an initial purge of two drams of 
castor oil. 



APHTHOUS STOMATITIS (HERPETIC STOMATITIS). 

This form of stomatitis is characterized by the formation of small, 
round, yellowish, superficial ulcerations on the mucous membrane 
of the lips, cheeks, palate, gums, and tongue, and is always accom- 
panied by a catarrhal stomatitis. 

Etiology. — Aphthous stomatitis occurs most frequently during the 
first three years of life. The actual cause is unknown; a nervous 
origin has been suggested, but is improbable. Some observers believe 
it to be an infection derived from the bowels, and caused by toxins 
generated in contaminated milk; while other authorities regard it as 
a local infection of the mouth. The theory of the infectious nature 
of aphthous stomatitis is, to my mind, the most probable. From 
this stand-point we may regard lack of proper hygiene of the mouth 
as a strongly predisposing factor, since aphthous stomatitis is most 
common during that period of infancy when the child crawls over 
the floor on hands and knees, and puts every object it grasps into the 
mouth. 

The French theory of a relation between aphthous stomatitis and 
the foot-and-mouth disease of cattle which is transmitted to the 
child through the medium of cow's milk I consider very obscure, and 
there is no evidence of the spread of this disease from one child to 
another. Most cases are seen in connection with some gastrointes- 
tinal disorder, or with one of the acute infections of childhood; but 
bacteriological examination of the oral secretions and the scrapings 
from the mouth fail to reveal any organisms other than those found 
normally in the mouth. 

Symptoms. — The initial lesions are small macules, usually found in 
the anterior part of the mouth, which become vesicles. These vesicles 
break and leave small ulcers, at first of a grayish-w T hite color, later 
turning yellow or grayish-yellow in the centre, and having a dark red 
areola. Ulceration is due to the death of the epithelium, which 
becomes elevated above the vesicle by an exudation in the mucosa, 
therefore the ulcers are very superficial. They vary in size from pin 
head spots to patches as large as 'a split pea, and, in some instances, 
are even larger as the result of the coalescence of several smaller ulcers. 

Any part of the mouth may be involved, but ulceration is most 
common on the tongue and inner surface of the cheeks. As a rule 
not more than a dozen ulcers are visible at one time, although fresh 
ulcers may appear as others heal. In no instance does the necrosis 



THR USH—SPR UE 25: > 

of tissue extend further than the mucous membrane, healing always 
taking place without scar formation. 

The gums are swollen, the tongue coated, the mouth is hot and 
dry, although there is hypersecretion of saliva. Pain is sometimes 
very severe, which discourages the taking of food. There is usually 
a; somewhat higher fever than in simple acute catarrhal stomatitis, 
and the child is dull, drowsy, fretful, and restless. The stomach and 
bowels become affected, there is diarrhea, and sleep is broken by 
intervals of restlessness; so that, if allowed to persist very long, 
aphthous stomatitis may precipitate a serious illness. Enlargement 
of the submaxillary glands is a common finding, but they never sup- 
purate, although there is sometimes pain on moving the jaw. 

Prognosis. — The prognosis of aphthous stomatitis is good, and the 
disease ordinarily runs its course in from one to two weeks, ending 
in spontaneous recovery. The ulcerations do not heal so quickly in 
weaklings and marasmic infants, and if vigorous treatment is not 
instituted, a mixed infection may take place which will render the 
case much more serious. 

Treatment. — The treatment of aphthous stomatitis differs but little 
from that of the acute catarrhal variety. The ulcerations tend to 
heal more quickly if touched with a 2 per cent, solution of silver 
nitrate twice daily, following each application by a mouth wash of 
cold water. After each feeding the mouth should be washed with 
a 25 per cent, solution of liquor alkalinus antisepticus, or an alkaline 
wash containing 15 grains each of bicarbonate of soda and borate 
of soda to the ounce of water. A 25 per cent, solution of hydrogen 
peroxide used three times a day as a mouth wash is very effective in 
clearing away the grayish-white and yellow patches of necrotic epithe- 
lium. As in the treatment of catarrhal stomatitis, an initial dose 
of two drams of castor oil to a child of one year should be given, 
and the nourishment kept up as fully as possible. Because of the 
hot and dry condition of the mouth, food will be taken much more 
readily if chilled before it is given, and the sucking of small pieces of 
ice affords great relief. 

THRUSH— SPRUE. 

Thrush is a mycotic infection of the mucous membrane of the 
mouth, seen most frequently in children of the poorer classes, and is 
regarded as indicating a poor state of the nutrition and general health 
rather than the direct result of poor oral hygiene. The fungus, oidium 
albicans, may be recovered from scrapings of the mouth in every 
case. It occurs in the yeast form and the mycelium, and under the 
microscope is revealed as long filaments, which frequently branch 
and unite to form chains, at each intersection of which will be a rounded 
cell, or several cells, containing spores. This fungus also propagates 
by filaments from conidia, and from isolated conidia. In certain 
respects it resembles the mould fungus and the yeast fungus, but 
cannot be satisfactorily grouped with either class. As a rule, the 



254 DISEASES OF THE GASTRO-INTESTINAL TRACT 

growth is confined solely to the mouth, but may extend to the nose, 
pharynx, larynx, or even to the stomach, although the gastric mucosa 
offers a very unfavorable site for thrush, since this fungus thrives 
best on a dry surface. 

Etiology. — Infection with the oidium albicans may come from a 
variety of sources, but the most important predisposing factor is a 
devitalized condition of the infant or child. The fungus, itself, is 
air borne; it has been found in the vaginal secretion, on the nipples 
of the breast, and has been isolated from the mouths of normal infants. 
Since thrush is most common in artificially fed babies, it is probably 
carried into the mouth in food and on artificial nipples, which have 
not been properly cleansed and sterilized. Although the devitalized 
mucous membrane in the mouths of weaklings and marasmic children 
is most susceptible to thrush infection, yet there must be an abrasion 
or break in the continuity of the surface of the mouth, such as would 
be produced by the contact of an improper nipple, before the fungus 
can find lodgment and grow. The disease is most prevalent in hos- 
pitals and foundling asylums, and in many institutions can be held 
in check only by careful oral hygiene. It is rarely seen before the 
baby is six months old. 

Symptoms. — The first manifestations of thrush are tiny white spots 
like curds of milk which appear on the tip of the tongue, the mucous 
membrane of the cheeks, and on the gums. These patches are adherent, 
grayish-white in color, elevated above the surrounding tissue, and 
vary in number and size from a comparatively few small patches, in 
mild cases, to a number of large areas formed by the coalescence of 
many smaller lesions. There may or may not be any appreciable 
inflammation of the surrounding mucous membrane; but, as a rule, 
there is a mild stomatitis, the mouth is dry, and the gums slightly 
inflamed although there is rarely any pain apparent to interfere with 
the taking of food. 

Gastro-intestinal disturbances are usually present at the height of 
the disease, and give rise to nausea, vomiting, diarrhea, and slight 
fever; only, however, in very weak and anemic children do actual 
lesions of the stomach occur, and these cases usually end fatally. 
When the growth extends merely to the nasopharynx and esophagus, 
a more favorable outcome may be expected, although the disease 
may persist for a greater length of time than when the mouth alone 
is involved. 

Diagnosis. — The diagnosis of thrush is, as a rule, easily made when 
the characteristic grayish-white patches appear throughout the 
mouth, accompanied by a very mild stomatitis. If any doubt exists 
attempts should be made to obtain scrapings from the mouth, and 
these, when examined under the microscope, reveal the presence of 
the oidium albicans. On casual inspection one may mistake the 
small white patches scattered over the mouth for milk curds; but 
their firm attachment to the mucous membrane shows their true 
nature, while their elevation above the surrounding surface with an 



ULCERATIVE STOMATITIS 255 

absence of ulceration serves to exclude the more serious forms of 
stomatitis. 

Prognosis. — Thrush in the normal healthy infant is of little conse- 
quence, and usually disappears promptly under appropriate treatment. 
It is the poorly nourished child, in whom thrush is complicated by 
severe gastro-intestinal disturbances, or in whom it appears as a com- 
plication of an already serious digestive derangement, that suffers 
greatly, or perhaps dies, from an attack of mycotic stomatitis. 

Treatment. — Prophylaxis is of paramount importance. It consists 
in absolute cleanliness, not only of the infant's mouth, but of every- 
thing that comes in contact with the child's mouth or food. Thus, 
the nurse's hands, the mother's breast, the nursing bottle, and the 
nipple should be kept as nearly sterile as possible, and the mouth 
should be cleansed after each feeding by giving the infant a table- 
spoonful of water. 

These precautions should be instituted immediately on the appear- 
ance of thrush; in addition, the mouth should be washed out three 
times daily with a saturated solution of boric acid, using a cotton 
swab when attempting to remove the various patches, but this must 
be done very carefully, lest the mucous membrane be abraded. When 
there are abrasions or superficial ulcerations, a 2 per cent, solution 
of silver nitrate should be applied daily. If, despite treatment, heal- 
ing is delayed, it is advisable to discontinue the use of an artificial 
nipple, and substitute dropper feeding or gavage until there is 
improvement. 

Gastro-intestinal complications should be met by careful regula- 
tion of the diet, restriction of the amount of food, and an initial purge 
of castor oil, two drams to a child of one year. The following pre- 
scription is useful, both for its tonic effect and its local beneficial 
action on the mouth, and may be given with little reservation, regard- 
less of the condition of the stomach: 

1$ — Tinct. ferri chloridi 5J 

Potassii chloratis gr. xxx 

Glycerini 5iv 

Aqua q. s. f 3 ii J 

Sig. — 3J in aqua every three hours. 

ULCERATIVE STOMATITIS. 

Ulcerative stomatitis is one of the most severe inflammations of the 
mouth seen in childhood, and occurs chiefly in the children of the 
poor, neglect being an important factor in its etiology. It does not 
appear until dentition has been established. The ulcerative process 
is always first noticed at the line of junction of the gums and teeth, 
the gums of the lower jaw being most commonly the site of the first 
ulcers, which rapidly extend along the teeth, and may involve the 
alveolus. 

Etiology. — Ulcerative stomatitis is very rare in private practice. 
The majority of cases are observed in dispensary patients and inmates 



250 DISEASES OF THE GASTRO-INTESTINAL TRACT 

of hospitals and asylums; therefore, lack of proper oral hygiene, 
together with a poor state of general health, may be considered an 
essential factor in its production. That improper diet also may be a 
cause is apparent from the fact that it accompanies scurvy. It may 
also occur as a sequel of typhoid fever, pneumonia, and the acute 
contagious diseases of childhood. Formerly, ulcerative stomatitis 
was not infrequently due to the ingestion of metallic poisons, among 
which mercury, lead, and phosphorus were the most common; but 
with the exception of mercurial poisoning, this is now quite rare. 

Carious teeth form, perhaps, the most frequent exciting cause; 
but there must also be a devitalized condition of the gums, due to the 
poor physical condition of most of these children. Some observers 
believe this form of stomatitis to be contagious, and claim that it 
may be transmitted, but this theory is not borne out to any great 
extent, although epidemics of ulcerative stomatitis have been observed. 
Bernheim and Pospischill made a bacteriological study of a number 
of cases, and from all but two of them a fusiform bacillus, resembling 
the bacillus of diphtheria, and a spirillum were isolated, both being 
present in each case, one or the other always predominating. 

Pathology. — At the onset of this disease the gums, usually about 
the lower incisors, become swollen and red; as the swelling increases, 
the teeth may be almost covered by the gums, which become very 
spongy, are of a dark red color, and bleed when touched. Ulcera- 
tions now form at the junction of the gums and teeth, spreading 
quickly along the whole line of junction, but usually confined to one 
jaw. 

In severe cases the teeth may become exposed and loosened, the 
lips and cheeks ulcerated; but the process is always limited to the 
oral cavity, the entire buccal mucous membrane showing an acute 
catarrhal inflammation. The junction of the gums and teeth is 
usually represented by a ridge of yellowish necrotic granulations, 
bathed in a mucopurulent exudation. In some cases the tooth sockets 
may become involved, and the necrotic process extend to the peri- 
osteum of the alveolar process, and even to the jaw-bone. 

Symptoms. — Pain is usually so severe when food is taken into 
the mouth that feeding is quite difficult. The tongue is coated, the 
breath foul, salivation increased, and neglected cases frequently show 
an eczema of the lips due to the constant dribbling of blood-streaked 
saliva mixed with pus. In very young children, there is usually mod- 
erate fever, and because of lack of nourishment they become restless, 
irritable, much weakened, and exhausted. On inspection of the 
mouth the swollen, inflamed, and bleeding gums are plainly visible; 
careful investigation may reveal loosened teeth and, perhaps, other 
ulcerations on the inside of the lips, cheeks, and even upon the 
palate and tonsils. It is only in most severe cases that the alveolar 
periosteum and the jaw-bone are found to be necrotic. 

Diagnosis. — The diagnosis is, in most instances, readily made from 
the condition of the gums and the extremely foul breath. The mild- 



GANGRENOUS STOMA TIT IS 25i 

oess of the constitutional symptoms, in comparison with the severity 
of the local affection in the mouth, is also an aid in diagnosis. 

Bednar's aphthae may he suggested, but if one recalls the fact that 
in this rare affection the ulcers are found only on either side of the 
raphae over the hamular process of the palate hone, no mistake will 
be made, since in ulcerative stomatitis the ulcerations may be found 
anywhere within the mouth. Gangrenous stomatitis may be differen- 
tiated from the ulcerative form by the severity of the constitutional 
symptoms, and the localization of the lesion to one particular 
area. 

Prognosis. — In this disease, as in the other forms of stomatitis, the 
course and prognosis depend to a great extent upon the vitality of 
the child. Fairly well-nourished children should show improvement 
within a week after treatment is instituted; but anemic and mar- 
asmic infants may not recover from ulcerative stomatitis for 
months although, in the majority of cases, the final outcome i- 
favorable. 

Treatment. — In the treatment of ulcerative stomatitis, the fir>t 
consideration should be directed to finding the cause of the attack, 
and removing it. The mouth should be kept absolutely clean by the 
use of antiseptic washes and cleansing agents such as a 25 per cent, 
solution of hydrogen peroxide, or 1 to 5000 solution of potassium 
permanganate, or a saturated solution of potassium chlorate. The 
ulcerations should be touched daily with alum, or a 10 per cent, nitrate 
of silver solution. 

Potassium chlorate is also valuable given internally in ulcerative 
stomatitis, if its administration is properly carried out. My plan 
has been to give a child of two or three years two grains every two 
hours the first day, and to reduce the total daily quantity one-half 
each succeeding day, as improvement is observed. If necrosis of *the 
jaw is suspected, the loosened teeth should be extracted, the jaw-bone 
carefully examined, and treated surgically if necessary. Because of 
the poor physical condition of these children, they should be placed 
in the most healthful environment, with fresh air, sunshine, and 
nourishing food in abundance. If due to scurvy, orange juice should 
be given daily; if anemia be marked, full doses of the syrup of ferrous 
iodide, or an amount of iron equal to this in any other form, will 
materially promote recovery. 

GANGRENOUS STOMATITIS. 

Gangrenous stomatitis, cancrum oris, or noma is a rare disease 
of the mouth which affects children of the poorer classes, and is 
characterized by the appearance of a small inflammatory spot on the 
cheek which quickly becomes necrotic, extends with tremendous 
rapidity, and may end fatally in a few days. This same disease is 
occasionally observed on the vulva, and more rarely on the anus and 
prepuce. 
17 



258 



DISEASES OF THE GASTRO-INTESTINAL TRACT 



Etiology. — Gangrenous stomatitis is most frequently seen in insti- 
tutions, being almost unknown in private practice. It is usually the 
sequel to a severe illness, perhaps one of the acute infections, par- 
ticularly measles; a predisposing factor is debility from any cause. 
Although several organisms have been described in connection with 
cancrum oris, among them a fusiform bacillus, a spirochete, and the 
streptococcus, the specificity of any one particular germ has not 
been satisfactorily established. In many cases catarrhal or ulcerative 
stomatitis has been the precursor of the disease. It is seen most 
frequently in that period of childhood between the first and second 
dentitions, and is as common in boys as in girls. 

Symptoms. — Following measles, or any other acute infectious dis- 
ease, or a long debilitating illness which has been complicated by 
catarrhal or ulcerative stomatitis, the child with beginning gan- 
grenous stomatitis is at once conspicuous by the foul gangrenous odor 




Fig. 28. — Gangrenous stomatitis. 



of the breath. On inspection of the mouth, a spot of beginning necro- 
sis will usually be found on the inner side of one cheek, this par- 
ticular area of mucous membrane being of a darker shade than the 
surrounding tissue. A bleb forms on the inside, and a corresponding 
brawny swelling on the outer surface of the cheek. The gangrenous 
spot increases rapidly in size, and the centre sloughs away, leaving 
a dark, necrotic, ulcerating surface which may result in perforation 
of the cheek. ' 

In severe cases, the gums become necrotic, the teeth loosen and 
fall out, even the jaw-bone becomes necrosed. A fetid discharge 
covers the affected parts, and emits a foul, penetrating odor which 
is characteristic of the disease. As a rule pain is very slight, even 
with perforation, and thrombosis of the vessels at the margin of the 
ulcer inhibits bleeding. 

The constitutional symptoms vary somewhat, but become severe; 



GANGRENOUS STOMATITIS 259 

fever, as a rule, is moderate; the child is dull, apathetic, extremely 
depressed or prostrated, and may become delirious because of the 
severe toxemia, further evidence of which is the extremely feeble 
action of the heart. The lymph nodes of the face and neck show 
general enlargement, diarrhea is always present, and the disease 
usually comes to a fatal termination by septic pneumonia. 

Diagnosis. — The diagnosis of gangrenous stomatitis is easily made 
when the disease is well established; but, at the onset, the initial 
lesion is extremely difficult to differentiate from simple ulcer of the 
mouth. Anthrax may be excluded by the history of the case and by 
bacteriological examination of scrapings of the mouth. 

Prognosis. — The prognosis of cancrum oris is unfavorable; few 
children survive; therefore only slight hope of recovery can be held 
out to the parents. 

Treatment. — Prophylaxis is the most important element in any treat- 
ment which can be said to be effective. The mouth should always 
receive the utmost attention during the course of any debilitating 
disease. It should be cleansed very gently, for too vigorous cleansing 
which results in abrasions of the mucous membrane is more harmful 
than none at all. If ulceration appears, the mouth should be care- 
fully inspected daily so that, at the first indication of approaching 
gangrene, the necrotic tissue may be widely excised. If necrosis be 
already advanced and extensive, the case is desperate; but an attempt 
may be made to cauterize the edge of the slough, going well into the 
living tissue at all points. For this purpose the actual cautery must 
be used, caustics and other cauterizing agents being of no value 
whatsoever. 

Attempts have been made to stop the ravages of this disease by 
means of the .r-ray, incandescent lamps, and injections of either the 
perchloride of mercury, carbolic acid, or tincture of iodin into the 
tissues at points in advance of the approaching necrosis; but radical 
surgical procedures, such as w T ide excision of the gangrenous tissue, 
multiple tooth extraction, and curettage of the jaw-bone have been 
more successful, when the condition of the patient warranted them. 
The mouth should be cleansed frequently with a 25 per cent, solution 
of liquor alkalinus antisepticus, and the ulcerated surface protected 
by a dressing. 

Although sometimes very difficult to prevent it, the child's strength, 
if possible, should not be allowed to fail. It should be given the 
most nourishing liquid food in small quantities every two hours, and 
be kept in the sunshine and fresh air as long as the slightest hope of 
recovery is entertained. Stimulation is necessary in every case, and 
20 or 30 drops of brandy may be given a child of two years, every 
two hours; if borne by the stomach, a half teaspoonful of the mixture 
of iron, quinine, and strychnine should also be given three times a day. 
In recent years, antistreptococcic and antidiphtheritic serum have 
been used to combat cancrum oris, but with little appreciable result, 



260 DISEASES OF THE G ASTRO-INTESTINAL TRACT 



PYORRHEA ALVEOLARIS. 

Pyorrhea alveolaris is a subacute or chronic inflammation of the 
pericemental membrane, and may appear at any time after the erup- 
tion of the teeth. The exciting cause is always of bacterial nature 
but the primary underlying factor of pyorrhea in childhood is gastro- 
intestinal toxemia. Bacterial invasion is favored by irritation pro- 
duced by the tartar deposited on the teeth and gums, and may also 
be brought on by trauma to the gums or by chemical and mechanical 
irritation. 

Symptoms. — The onset of pyorrhea alveolaris is, as a rule, sudden, 
and pain is usually the first symptom. The gums become swollen, 
are painful on pressure, and the teeth are loosened by recession of the 
gum margin. On inspection of the mouth a purulent discharge may 
be observed to exude from the gum margin, and this accounts, in a 
measure, for the foul breath and coated tongue which these children 
present. In most instances this pus is swallowed, and by its presence 
either gives rise to fermentation of the stomach or to direct absorption 
of the toxins into the child's system. The effect of pyorrhea locally 
is to favor to a great degree the entrance and growth of many patho- 
genic organisms, particularly the bacilli of influenza and diphtheria. 

Treatment.— The child affected with pyorrhea alveolaris should 
be sent to see a dentist in order that the teeth may be thoroughly 
cleansed and deposits of tartar removed, after which an antiseptic 
mouth wash composed of equal parts of hydrogen peroxide and 
extract of witch hazel should be used at least every two hours the first 
day or so, and less frequently thereafter. The diet should not be 
reduced in amount, but the food must be so soft that mastication is 
unnecessary, lest the gums become traumatized by the act of 
chewing. 

When pyoirhea does not respond to the foregoing treatment, a 
culture should be obtained from the discharge, and an autogenous 
vaccine be made, the dosage of which would depend largely upon 
the organism grown and the effect of the treatment outlined uoon the 
disease. Recent observations of the beneficial effect, in most cases, 
of the hypodermic administration of emetin hydrochloride, seem to 
recommend a trial of this therapeutic measure. 

UVULITIS. ' 

Acute inflammation of the uvula is rare during childhood, and 
practically unknown in infants. Children with congenital elongation 
of the uvula are especially predisposed to attacks of uvulitis; and, 
since each attack still further elongates the organ, recurrent uvulitis 
is quite common. 

Etiology. — Uvulitis not infrequently occurs in association with gastro- 
intestinal disturbance and rachitis, and in rare instances may be pro- 
duced by the ingestion of hot liquids, strong acids, or alkalies. The 



ESOPHAGI TIK 261 

most common cause of uvulitis is the extension of an Inflammatory 
process in the pharynx or tonsils. 

Symptoms. — The most distinctive symptom of uvulitis is a persistent 

unproductive cough, due to an attempt to relieve the irritation pro- 
duced by the pressure of the uvula on the base of the tongue, fauces, 
or upper part of the larynx. There is also a constant desire to swallow, 
even though swallowing be painful, for the swollen uvula feels like 
a foreign body in the pharynx, and in severe cases it may attain such 
a size that the oropharyngeal opening is occluded, thus causing dyspnea 
and attacks of suffocation. When the swelling of the uvula reaches 
these proportions, it interferes with the taking of food, and the child 
may become weak and exhausted from lack of nourishment. Other 
constitutional symptoms are rare. 

Diagnosis. — The diagnosis of uvulitis is very simple, and readily 
made by inspection of the mouth, which reveals the swollen, boggy, 
edematous uvula, very much altered in shape, and so enlarged as to 
be in contact with the base of the tongue and the fauces. 

Treatment. — At the onset of inflammation, uvulitis may sometimes 
be aborted by swabbing the uvula every hour with a 1 to 20, 000 
solution of adrenalin chloride. After the uvula has become edematous, 
adrenalin has little permanent effect; but the swelling may be greatly 
relieved by the application of a 2 per cent, solution of tannic acid three 
times daily. A gargle of Dobell's solution should be used every three 
hours; if the child be too young to gargle, this solution may be sprayed 
upon the throat. Great relief will be afforded by allowing the child 
to suck small pieces of ice, and by cold applications to the neck. 

In mild cases of uvulitis the foregoing measures are usually effectual ; 
but when swelling of the organ becomes so great as to produce dyspnea, 
more radical treatment is often necessary. Multiple puncture of the 
uvula with a short bistoury or double-cutting aspirating needle is 
the quickest and most satisfactory method of relieving the tension, 
and is not attended by any danger. If the inflammation shows a 
tendency to chronicity, the tip of the uvula should be excised. 



DISEASES OF THE ESOPHAGUS. 



ESOPHAGITIS. 

Acute inflammation of the esophagus is much more rare in children 
than in adults. Occasionally it is produced by the extension of inflam- 
matory processes in the mouth or pharynx; but usually it is due 
either to the ingestion of strong acids or alkalies, or to the impaction 
of a foreign body which the child has attempted to swallow. 

Symptoms. — The symptoms of acute esophagitis are largely depen- 
dent upon the cause. If there be but slight injury to the mucous mem- 



262 DISEASES OF THE GASTRO-INTESTINAL TRACT 

hrane, there is merely a little pain on swallowing and slight elevation 
of temperature for a few days, but when strong acids or corrosives 
have been swallowed the symptoms are most severe, and death may 
ensue in a few hours. The child is usually prostrated. It vomits 
shreds of bloody mucus. Thirst is extreme. There is severe burning 
pain under the sternum, and every attempt to swallow causes such 
suffering that the taking of liquids is exceedingly difficult. If the 
patient survives this period of acute symptoms, there still remains 
the danger of edema of the glottis which sometimes comes on during 
the succeeding two days. Not until a year has elapsed may we feel 
sure that no ill effects will follow; for stricture of the esophagus may 
appear at any time from two weeks to several months after the 
accident. 

Treatment. — The mild form of esophagitis heals spontaneously 
within a few days, hence treatment is unnecessary except the restric- 
tion of the diet to bland liquids at a moderate temperature. Cases 
due to poison should receive antidotes immediately, and an effort 
be made to empty the stomach. Stimulation is often necessary, and 
the strength may be supported by hypodermic injections of morphine 
sulphate, gr. ^o, and atropine sulphate, gr. yinr (for a child of five 
years), also by the rectal injection of brandy, 3ij> in an ounce of black 
coffee. This may be repeated every three hours until all danger from 
collapse is passed, and then the child should be closely watched for 
signs of edema of the glottis. Nourishment should be kept up by 
means of nutrient enemata, and codeine sulphate, gr. y 1 ^, may be 
given for the relief of pain. If stricture occurs as a sequel, surgical 
intervention is necessary. 

RETROESOPHAGEAL ABSCESS. 

Retroesophageal abscess is a very rare affection, caused either by 
the breaking down of the retroesophageal lymph nodes or by the 
extension of a suppurative process due to Pott's disease. It is most 
frequently seen in association with tuberculosis, but may follow 
measles, scarlet fever, or diphtheria. 

Symptoms. — Among these are an irritating spasmodic cough and a 
decided change in the voice. The breathing is stertorous. Dyspnea 
occurs spasmodically, and is most marked on inspiration. The neck 
is swollen externally, and all the cervical glands are greatly enlarged. 
The temperature often runs up to 102.5° F. or above, and the pulse 
and respiration are accelerated. 

Prognosis. — In retroesophageal abscess the prognosis is unfavorable. 
Most cases die from pressure on the pneumogastric nerve or rupture 
of the abscess into adjacent structures. An instance is reported of 
recovery after rupture of such an abscess into the esophagus. 

Treatment. — The treatment is surgical ; the abscess should be opened 
and drained. If the child is tuberculous, it should be removed from 
any crowded surroundings and sent to the seashore. The diet should 



PLATE II 




Stricture of the Esophagus in a Child Aged Two and a Half 
Years, due to Swallowing Lye. 

R., right side; L., left side. 1, dilated portion of esophagus above 
constricted portion; 2, marked irregularity in lumen of esophagus; 
3, narrowed portion of lumen; A, the stomach. 



VOMITING 263 

be so adjusted as to consist of most nourishing food, and a tonic, 

such as cod-liver oil or the syrup of the iodide of iron, may be given 
if the stomach is not upset by this medicine. 



DISEASES OF THE STOMACH AND INTESTINES. 

VOMITING. 

Vomiting, although merely a symptom, occurs so frequently in 
infancy and childhood, and arises from such a variety of causes, that 
special discussion of this subject is warranted. 

In Early Infancy. — The newborn infant may vomit immediately 
after each nursing, even though perfectly healthy. This is usually 
caused by the infant swallowing the breast milk too quickly or by 
overfeeding, and is a conservative measure on the part of the stomach 
to prevent overtaxation of the digestive organs. Various reasons 
have been adduced to explain this symptom, and it is probable that 
other factors may be responsible for vomiting in the breast-fed infant, 
since regulation of the quantity and the time of feeding does not 
always correct the condition. 

The stomach of an infant, lying as it does in an almost upright 
position so that it forms a nearly continuous line with the esophagus, 
is easily emptied by slight pressure such as might be created by the 
movements of the diaphragm during respiration. There is neither 
nausea nor epigastric pain in this form of vomiting; the milk usually 
returns only slightly changed or curdled; and, although the condition 
may persist, no appreciable loss of weight results. It is always well 
to investigate the feeding of an infant in whom this form of vomiting 
is observed; but if correction and regulation of the nursing do not 
relieve it, no further treatment can be instituted, and the condition 
may with safety be allowed to continue, as it will cease spontaneously 
in due time. 

Symptomatic Vomiting. — -Vomiting in later infancy and in childhood 
is always significant of some disorder, and should never be regarded 
or treated as an independent affection. In extremely few cases it 
may be said to have become a habit, the attack being apparently a 
voluntary act on the part of the child during a crying spell or fit of 
anger. By far the most common cause of vomiting is indigestion, 
either chronic or acute, and when due to this cause it is accompanied 
by pain in the stomach as well as nausea. The vomited material 
indicates clearly the source of irritation, for it is composed of undi- 
gested sour-smelling food or curds of milk. This form of vomiting 
should receive careful attention and treatment from its very begin- 
ning, since it is indicative of digestive disturbances which, if allowed 
to continue, may become chronic. 



264 DISEASES OF THE GASTRO-INTESTINAL TRACT 

In young children any cough, if at all severe, will produce vomiting, 
and in pertussis, especially, the child vomits at each paroxysm. 
Keflex vomiting is also provoked by irritation of the pharynx from 
an elongated nipple, by the habit of hand sucking, or by eye-strain, 
earache, dentition, or intestinal worms. The projectile vomiting 
of meningitis is reflex in character, and although it commonly appears 
at the onset of the illness it rarely recurs. The same form of vomiting 
is observed in cases of brain tumor and in cerebellar disease, but 
without other signs of digestive disturbance. 

Aside from indigestion, perhaps the most common cause of vomit- 
ing is intestinal derangement, which need not necessarily be of inflam- 
matory nature, since it often results from the absorption of toxins 
in the upper and lower bowel. Vomiting is often the first symptom 
of intestinal obstruction, whether from volvulus, intussusception, 
or fecal impaction, and persists until the obstruction is relieved, 
becoming stercoraceous in the end. In appendicitis also it is a promi- 
nent symptom at the onset, but does not continue throughout the 
attack unless peritonitis sets in, and in peritonitis it invariably indi- 
cates extreme irritability of the visceral peritoneum. Obstruction 
higher up in the alimentary canal, and commonly at the pylorus or 
esophagus, is also accompanied by vomiting which, however, is more 
of the nature of regurgitation. In pyloric stenosis particularly, there 
is constant regurgitation of small quantities of food with intermittent 
periods in which the amount of vomitus is far in excess of the quantity 
of food taken at the preceding nursing, since it represents the residue 
of several previous feedings which have been retained by the greatly 
dilated stomach. 

Some children, and many infants, vomit whenever there is an 
elevation of the body temperature of 2° or 3°, regardless of the cause 
of the pyrexia, and, in most of the acute infections, vomiting is one 
of the premonitory symptoms. There undoubtedly occurs a neurotic 
form of vomiting which is induced by excitement, fright, fear, or 
fatigue, especially in children with a tainted nervous heredity. There 
are other, and trivial, causes of vomiting which have not been dis- 
cussed; but, before attributing vomiting to some slight incident or, 
occurrence, the patient should be thoroughly examined for signs of 
one of the grave diseases which may possibly be present. 

Cyclic Vomiting. — Cyclic vomiting is comparatively rare and is 
peculiar to children. As the term implies, there are periodical attacks 
of vomiting which occur at intervals of weeks or months, without 
other signs of gastric disturbance. This condition is of such impor- 
tance that it is described as a distinct disease, although it has not 
been proven to be a primary affection of the stomach. During the 
attacks the stomach is extremely intolerant to food of any kind or 
even water, and prostration is sudden and extreme. 

Etiology. — The direct cause of cyclic vomiting is unknown, but 
from observation of a number of cases it is evident that a variety of 
factors are operative in its production. Feeding seems to be of minor 



VOMITING 265 

importance, since the affection is observed in children whose diet is 
ideal; hence it may be assumed in the majority of cases that the 

impulse arises from a source outside the stomach, in further support 
of which assumption is the apparent absence of gastric derangement 
in the intervals between the attacks. A great many children who 
suffer from cyclic vomiting are of a neurotic disposition, and since 
it practically occurs only during childhood, when the nervous system 
is as yet unstable, it is quite possible that a nervous element is active 
in its causation. 

The fact that in a number of instances acetone and diacetic acid 
have been demonstrated in the urine of these patients, and that the 
breath has had a pear-like odor, has firmly supported the view that 
cyclic vomiting is a result of acidosis. This theory is further borne 
out by the effects of alkaline treatment. It is quite probable that in 
cyclic vomiting we have the symptom-complex of gastro-intestinal 
lithemia due to an increased acidity of the body fluids as a result of 
disturbed metabolism, and the importance of gastro-intestinal auto- 
intoxication as a causative factor cannot be overlooked, since in many 
of these children there is a history of constipation for long periods 
before each attack. 

Symptoms. — An attack of cyclic vomiting usually lasts from one to 
three or four days, during which time there are intervals of from 
three to six hours in which vomiting ceases, only to be repeated, until 
the attack is over. The vomitus, at first, is composed of undigested 
food, although little or no other evidence of indigestion is present; 
later the vomited material contains mucus which may be tinged with 
blood or bile. The child becomes extremely thirsty, but ejects every 
drop of water swallowed; consequently, after a few attempts, drink- 
ing is abandoned and the little one simply lies quietly on its back. 
There is occasional complaint of pain in the stomach, both before 
and during an attack, and constipation is usually present. The 
temperature, as a rule, is normal or subnormal. The pulse at first 
is slightly accelerated and strong, but becomes weak when exhaustion 
sets in. 

After two or three days the attack may suddenly cease or, in some 
instances, the vomiting gradually decrease in severity and frequency 
until it stops altogether, when the child quickly regains strength, 
and may be perfectly well' for weeks or months until another attack 
supervenes. As a rule, the attacks cease entirely at puberty, although 
rare cases have been reported in which cyclic vomiting continued to 
recur until adult life. 

Diagnosis. — Unless one can obtain a history of preceding periodical 
attacks, the diagnosis of cyclic vomiting is difficult, and should only 
be made after careful exclusion of the more common causes of vomit- 
ing, and in the absence of any signs or symptoms of gastro-intestinal 
derangement. Among the many causes of vomiting which must be 
excluded are tuberculous meningitis, volvulus, intussusception, and 
appendicitis. Absence of fever is significant as eliminating inflam- 



266 DISEASES OF THE GASTRO-INTESTINAL TRACT 

inatorv lesions of the gastro-intestinal tract, and a rapid pulse and 
good physical condition of the child usually exclude tuberculous 
meningitis. 

Prognosis. — The prognosis of cyclic vomiting is, on the whole, favor- 
able, since the majority of children survive the most severe attacks, 
and quickly regain their normal health and vigor when the vomiting 
ceases. 

Treatment. — When an attack of cyclic vomiting comes on, the 
child should be put to bed, and for twenty-four hours nothing should 
be given it by mouth but a few sips of water. It is a good plan to give 
an enema as soon as an approaching attack is suspected, and the 
injection may be repeated once or twice daily until vomiting ceases. 
After twenty-four hours the very lightest nourishment, preferably 
albumin water or weak broth, may be allowed in small quantities, 
and, if this is not retained, nutrient enemata may be resorted to. 
If fluids do not excite vomiting, soft food may be given the child on 
the following day, and full diet gradually resumed. 

For the control of vomiting, morphin and codein are the most 
efficient drugs, but the dosage should be carefully graduated accord- 
ing to the age, because of the idiosyncrasy of children to opiates. In 
view of the fact that acidosis is frequently responsible for cyclic vomit- 
ing, an alkali, such as sodium bicarbonate, which may be given in 
10- to 20-grain doses every hour, will often bring about excellent 
results. Older children may be given larger doses; and, if the infant 
or child does not retain this drug when given by mouth, twice the 
dose should be administered by rectum. In the course of a day the 
infant should receive 1 dram, and the child 2 drams, if the drug is 
to have any appreciable effect. 

The diet of these children should be very much restricted in its 
carbohydrate content because of the acidosis and evident relation 
between cyclic vomiting and inefficient carbohydrate metabolism. 
Salt water bathing and massage are valuable adjuncts to the treat- 
ment. In addition to the specific measures outlined above, these 
children often improve if given the advantage of hygienic surround- 
ings. As a prophylactic measure against future attacks, the bowels 
should be so regulated as to make sure of a daily movement. 

GASTRALGIA. 

Gastralgia is neuralgic pain in the abdomen, usually located in 
or about the stomach, and due to irritation of the sensory gastric 
nerves. It is quite common in infancy. Little or nothing is definitely 
known as to its etiology, since it occurs regardless of whether the 
stomach is empty or full; therefore it is apparently reflex, and due 
to external, constitutional, or visceral disturbances. 

Symptoms. — The attacks usually come on suddenly, and may last 
for a few minutes or several hours, during which time the patient 
may be prostrated. Vomiting is rare. The epigastrium shows no 



INDIGESTION 267 

sign of tenderness upon palpation, and recovery is prompt when the 
pain ceases. 

Diagnosis.— The diagnosis of gastralgia should always be held in 
reserve until every other possible cause of abdominal pain is excluded. 
This involves careful and thorough history taking, as well as physical 
examination, especially in very young children who are unable to 
locate the pain. 

Treatment. — The child should be put to bed, and a hot application, 
such as a mustard plaster, hot water bag, or a turpentine stupe, may 
be placed over the epigastrium. Internally, hot water with 5 to 10 
drops of spirits of chloroform, or 10 to 30 drops of brandy or gin, 
or a teaspoonful of peppermint water, will often give relief. If these 
measures fail and the condition grows worse, the child should be closely 
watched for signs or symptoms of more serious nature. 

Children who suffer from repeated attacks of gastralgia need a 
carefully regulated diet, and their bowels should be moved at least 
once daily. The administration of Fowler's solution, 1 drop doses 
three times a day, to a child of five years, and smaller doses to younger 
children, gradually increased to the point of tolerance, is of great 
value in the prevention of subsequent attacks, if kept up throughout 
the interim. Tincture of mix vomica, in 2 drop doses, may also be 
given, either alone or in combination with arsenic. These children 
should spend most of their time in the open air, but overexercise 
must be guarded against, as fatigue is very harmful. 

INDIGESTION. 

Fat Indigestion. — Indigestion during infancy, both in the nursling 
and in the bottle-fed baby, is quite often to be attributed to an excess 
of fat; and since in infancy the digestion of fat is accomplished for 
the most part in the small intestines, the symptoms of fat indigestion 
are chiefly referable to the intestines, and are to be discerned in the 
stools. Vomiting is a common symptom in these cases. In the 
infant's stomach a fat-splitting ferment is present. 

Etiology. — Indigestion caused by an excess of fat in the ingested 
milk is far less common in the breast-fed infant than in the bottle-fed 
baby; but the nursling may also suffer from fat indigestion because 
of an idiosyncrasy to fats. This, however, is quite rare. 

In another case the mother, believing that her milk is poor, may 
give her child a teaspoonful or two of cream with each nursing under 
the erroneous impression that the more fat the baby takes the fatter 
it will grow. As a result, the child ingests an amount of fat far in 
excess of its actual need or digestive capability. In artificially fed 
infants fat indigestion is quite common because of the prevailing 
tendency among physicians, when making up formulas, to prescribe 
an excessive percentage of fat rather than one too low. 

Symptoms. — The breast-fed infant rarely suffers much from an 
excess of fat, even though the mother's milk be too rich; for, if exces- 



268 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

sively fat, regurgitation follows each feeding, and the child usually 
soon becomes able to digest a slightly higher percentage than normal. 
In addition to regurgitation the baby loses its appetite, this also 
being a conservative measure on the part of Nature to limit the quan- 
tity of fats ingested. The bowels become loose, the stools contain 
fat curds and fat-free globules, and there is usually much flatulence 
and colic. 

Continued disturbance in the digestion of fats results, first, in a 
failure to gain weight, and, subsequently, in loss of weight; but, as 
a rule, in the nursling fat indigestion is not attended by any serious 
impairment of health. The bottle-fed baby, however, usually fares 
worse. The symptoms of fat indigestion already enumerated become 
exaggerated, and, in addition, high fever generally accompanies the 
acute digestive disturbance. The stools may be either very loose, 
green in color, and composed of curds and mucus; or very watery 
and acid in reaction; or dry and well formed, and of a whitish or 
grayish color — the "soap stool," formed by a combination of fat and 
an alkaline salt. In some instances the loss of alkaline salts in the 
stools may be so great as to cause a relative acidosis with the 
characteristic symptoms of acid intoxication, such as increase in 
the respiratory rate, stupor, or extreme restlessness. 

If acute fat indigestion is not relieved within a short time it soon 
becomes chronic, and, not only is the digestive power of the infant 
impaired, but other disturbances of metabolism arise and result in 
rachitis, infantile atrophy, or "marasmus." Loss of weight is progres- 
sive and continuous, and even though the child be given excellent 
care recovery is at best a slow and tedious process. 

Treatment. — When indigestion is due to an excess of fat in the 
mother's milk, the amount taken at each feeding should be reduced 
by shortening the nursing period. We can also lower the fat content 
of the breast milk by giving the baby a small quantity of water imme- 
diately before it nurses. If the infant is losing weight because of 
insufficient food, the interval between feedings may be shortened so 
that the child will get the same amount of nourishment at each feed- 
ing as it previously received, but be fed more often in the twenty-four 
hours and, consequently, receive a larger amount of food. 

The percentage of fat in the mother's milk may also be to some 
extent decreased by reducing her diet, especially with regard to pro- 
tein, and by increasing the amount of exercise she takes. Since the 
milk obtained when the breast is almost empty is richest in fat, it 
is advisable to let the infant nurse only half the contents of each 
breast rather than to take the full feeding from one breast. If these 
measures fail to adapt the breast milk to the infant's digestive powers, 
it is sometimes necessary to procure a wet nurse. 

In these cases where the mother has been in the habit of giving 
the child a teaspoonful or so of cream in addition to the breast milk, 
it is a simple matter to relieve fat indigestion; for on discontinuing 
the practice the condition soon passes away. Intolerance to fat is 



INDIGESTION 269 

fortunately very rare; but, when encountered, the sole resource is 
skimmed milk, and it is only with greatest difficulty that the caloric 
requirements of the infant can be supplied. 

When fat indigestion arises in artificially fed infants, a fat-free diet 
should be instituted, and, for two or three days at least, no fats what- 
ever be allowed. After this time a small amount may be added to 
each feeding, and the percentage of fat gradually increased from time 
to time, according to the degree of tolerance established. 

An indication as to the proportion of fat being digested is readily 
furnished by observation of the stools, which should be carefully 
examined whenever the amount of fat is to be increased. Any evidence 
of excessive fat ingestion calls for immediate reduction in the percent- 
age of fat, as intolerance is very quickly precipitated; and it is much 
safer to increase the amount of protein and carbohydrates if the 
formula be too weak, although it is difficult to furnish in this way 
an equal number of calories without setting up digestive disturbance. 
When there is an idiosyncrasy to the fat of cow's milk, a wet-nurse 
should be secured, since, as a general rule, in these cases human milk 
is well borne, whereas it is impossible to change the character of the 
fat in cow's milk or to modify it in any way. 

In the summer months many cases of fat indigestion may be pre- 
vented by reducing the percentage of fat in the feeding mixtures, as 
even healthy infants show a greater intolerance to fat at this season 
of the year. In the treatment of fat indigestion it is usually wise to 
give an initial purge, castor oil in full dosage being most effective. 
If the case be very severe, the stomach should be given a rest by 
withholding all food for from twelve to twenty-four hours after 
purgation. 

Carbohydrate Indigestion. — Sugar indigestion in the breast-fed 
infant is quite rare, but is readily induced in artificially fed babies, 
either because they have ingested an excessive amount of carbohy- 
drates or have taken an unsuitable form of starch or sugar. 

Etiology. — The amount of sugar in human milk seldom varies more 
than 1 or 2 per cent. As a rule, this excess is readily digested by 
the healthy infant. Only in exceptional cases do digestive disturb- 
ances arise, and they are usually very mild, being marked by vomit- 
ing, diarrhea, eructations of gas, and more or less colic. The stools 
are thin, green in color, acid in reaction, and they frequently irritate 
and excoriate the buttocks. When carbohydrates are given in addi- 
tion to the breast milk for their laxative effect, or mixed feeding is 
resorted to, and an excess thus received, the symptoms are more 
severe. In artificially fed babies sugar indigestion can most fre- 
quently be attributed to the substitution of cane sugar for lactose 
or to the too liberal use of sugar of milk. In rare instances there is 
a marked intolerance to milk sugar in even the smallest quantities, 
and a more suitable carbohydrate must be substituted; but, as a 
rule, sugar of milk is very well borne by artificially fed infants if the 
feeding mixture does not contain more than 6 or 7 per cent. 



270 DISEASES OF THE GASTRO-INTESTINAL TRACT 

Symptoms. — Two forms of carbohydrate indigestion are met with — 
the acute and the chronic — and the symptoms vary according to the 
particular form of starch or sugar which causes the disturbance. 
In all cases of this nature diarrhea is the most prominent symptom, 
the stools being very loose, watery, and at times frothy. They are 
grass-green in color, acid in reaction, and frequently contain mucus. 
Colic is severe owing to excessive fermentation and flatulence, the 
latter being demonstrated by frequent eructations of gas which 
usually afford relief. The buttocks are irritated and excoriated by 
the highly acid stools, while the excessive ingestion of sugar causes 
an eczematous condition of the face, and of the scalp as well. The 
vomiting in sugar indigestion is not severe, and the vomitus has no 
special characteristics, although it is usually highly acid in reaction. 

In acute cases there is often a sharp rise of temperature which is of 
short duration, and loss of weight may be quite rapid. Associated 
with this high fever and rapid loss in weight, there may be decided 
toxemia with dulness or even decided stupor. In chronic cases, how- 
ever, there is no fever and very little, if any, wasting, for the assimila- 
tion of large quantities of sugar causes an increase in body weight. 
Carbohydrate intoxication may occur in acute and severe cases, and 
is then usually attended by marked disturbance of the nervous system 
and prostration. 

Cane sugar when given in excess produces the same symptoms as 
sugar of milk, but is less irritating to the intestinal mucosa. Starch 
ingested in excess usually causes chronic indigestion, which results 
in disturbances of nutrition rather than digestion. Pure maltose is 
never used in infant feeding; but preparations of dextrin-maltose 
are sometimes employed, and if given too freely produce much the 
same symptoms as those caused by too much milk sugar except that 
there is more fermentation, and colic and flatulence are more distress- 
ing. The stools, too, are dissimilar, being usually of a dark brown 
color. As a rule infants suffering from carbohydrate indigestion 
do not apparently lose in weight and may even seem to gain; but 
they are pale and anemic, and if closely scrutinized their muscle tissue 
is found to be loose and flabby so that, in reality, they are in poor 
physical condition and aie less able than normal children to combat 
a severe illness, or to endure the prolonged strain often associated 
with an intercurrent infection. 

Prognosis. — In acute forms of carbohydrate indigestion the infant 
may be quite ill, but the prognosis is somewhat more favorable when 
the disturbance is due to dextrin-maltose or starchy preparations 
than when caused by an excess of some other form of carbohydrate. 
Chronic cases usually recover, but improvement is apt to be slow, 
and not a few of these infants succumb to some acute intercurrent 
infection . 

Treatment. — An excess of lactose in the mother's milk is usually 
ascribed to a too generous diet — too rich, not only in carbohydrates, 
but in other food elements as well, Therefore, when sugar indigestion 



INDIGESTION 271 

appears in a suckling, the diet of the mother should be cut down, and 
other steps taken to render her milk less rich. When sugar of milk 
is the causative factor in artificially fed infants, the amount ingested 
should be restricted as far as possible, and the percentage of fat also 
decreased. In these cases fats act as an irritant to the intestinal 
mucosa, and consequently are not well borne in full quantities. If 
possible, milk sugar should be absolutely withheld for a few days, 
as lactic acid fermentation in the intestine will persist if even a small 
quantity is given. 

Since mother's milk contains 7 per cent, of lactose, and cow's milk 
about 4 per cent., the elimination of sugar of milk from a mixture 
without a dangerous reduction in its caloric value is not an easy task. 
Protein is well borne, however, and these infants show a tolerance 
to small quantities of starch, therefore by giving a mixture of skimmed 
milk with a cereal diluent, the caloric needs of the infant are fairly 
well supplied, and at the same time but a low percentage of fats 
and carbohydrates is being ingested. After a few days it is usually 
possible to add dextrin-maltose to the mixture, and then gradually to 
return to milk sugar. Cream whey mixtures are contraindicated 
because of the relatively high percentage of milk sugar in whey, but 
Eiweissmilch or, as it is often called, albumin milk, is usually well 
borne. 

When an excess of dextrin-maltose has set up indigestion, the treat- 
ment is practically the same as in acute carbohydrate indigestion 
from an excess of lactose; but, after dextrin-maltose has been omitted 
from the feedings for a few days, sugar of milk should be substituted. 
Indigestion due to an excess of starch is usually chronic, and the per- 
sistent gastro-intestinal derangement so weakens the digestive powers 
of the infant that, in addition to withdrawing starch from the food, 
fats and protein also must be considerably reduced, or, better still, 
if possible, mother's milk be given instead of a feeding mixture. If 
a wet-nurse cannot be procured, a cream whey mixture, or a rather 
weak formula containing not more than 2 per cent, of fat, 4 per cent, 
of sugar, and 1 per cent, of protein should be given, and these propor- 
tions gradually increased. At the onset it is always well to give the 
gastro-intestinal tract a thorough cleansing by a full dose of castor 
oil, and in severe cases the stomach should be given complete rest by 
withholding everything but water for twelve to twenty-four hours 
following the purge. 

Protein Indigestion. — Food injuries in the breast-fed infant are more 
often due to an excess of protein in the mother's milk than to an 
excess of either fat or sugar. The artificially fed baby suffers from 
protein indigestion only when cow's milk forms a part of the feeding 
mixture; for even though it is able to digest a higher percentage of 
protein than is found in mother's milk, the protein in cow's milk con- 
tains so much casein that an infant fed on a cow's milk mixture can 
easily receive an excessive amount of casein, and indigestion be the 
result. 



272 DISEASES OF THE GASTRO-INTESTINAL TRACT 

Etiology. — A high percentage of protein in mother's milk is usually 
the result of an excessive protein diet on her part, and either an excess 
or a lack of exercise. The milk of neurotic mothers and those who 
have been subjected to nervous shock, such as grief, worry, or fright, 
is apt to contain a higher percentage of protein than normal, and 
during the first ten days of lactation, before the equilibrium of milk 
secretion is definitely established, the milk contains more protein 
than it does later. The quantity of protein in human milk may be 
as high as 4 per cent. ; but the excess is rarely more than 2 per cent, 
above normal. In artificially fed infants protein indigestion is usually 
induced by an excess of casein, and is but rarely caused by a high 
percentage of whey. Exceptional cases have been recorded of infants 
who have shown evidence of anaphylaxis to the protein of cow's milk, 
and were unable to digest the smallest quantities, owing to sensitiza- 
tion of the system from absorption of the protein of cow's milk during 
the first few days after birth, when the intestines were in an abnormal 
condition. 

Symptoms.— Habitual colic is one of the most characteristic symp- 
toms of excessive protein ingestion during early infancy, whether in 
the breast-fed or bottle-fed infant. In the nursling the other symp- 
toms of protein indigestion are slight. Vomiting is rare, but there is 
usually considerable flatulence. The stools are loose, watery, and of 
a brown color; they contain mucus, and quite frequently fat curds 
due to an accompanying inability to digest fats. The temperature 
is not elevated except in extremely acute cases, when a sharp rise may 
occur. Breast-fed infants, as a rule, show no marked disturbance of 
nutrition as a result of protein excess, and lose very little weight. 
In infants who are being fed an excessive amount of whey protein 
digestive disorders can usually be attributed to an excess of sugar 
and salts in the whey, since whey itself rarely gives rise to indi- 
gestion. 

Casein, on the other hand, owing to the large, hard curds it forms, 
may derange the digestion. The symptoms produced by an excess 
of casein may be quite severe. Vomiting is not unusual, the vomitus 
containing large curds which are hard and tough in contrast to the 
soft curds found in fat indigestion. These curds may also be seen 
in the stools as white, gray, or green particles, frequently covered 
with a coating of mucus when passed. As a rule, diarrhea accom- 
panies this form of the affection, but constipation is not uncommon, 
and in some instances the stools are normal in every respect except 
for the presence of curds. Colic and flatulence are usually severe, 
and evacuations of the bowels may be accompanied by much pain. 
Ordinarily there is little or no elevation of temperature. 

Prognosis. — The prognosis in protein indigestion is much more 
favorable than when the disturbance of digestion is due to an excess 
of fat or carbohydrates. Breast-fed infants, as a rule, rapidly recover 
when the excess of protein is removed from the mother's milk; and, 
since it is a simple matter to reduce the percentage of protein in 



INDIGESTION 273 

feeding mixtures, artificially fed babies rarely suffer any serious or 

lasting ill effects. 

Treatment. — When the breast milk is found to contain an excess 
of protein, the cause of this excess should be ascertained and counter- 
acted as quickly as possible. If the diet be too rich it should be cut 

down; if the mother is taking too much exercise she must stop short 
of fatigue in the future; and if her life has been too sedentary she must 
be induced to take a moderate amount of exercise. Grief, worry, 
anxiety, and other nervous states should always be guarded against 
during lactation. In the bottle-fed baby protein indigestion can 
usually be relieved by reducing the percentage of casein in the feed- 
ing mixture, and substituting whey protein in order to satisfy the 
protein needs of the infant. 

The formation of large casein curds may also be prevented by pep- 
tonizing the milk or by the addition of alkalies, such as lime water, 
or solution of sodium bicarbonate, or cereal diluents, such as barley- 
water or rice-water. Sodium citrate added to milk also prevents 
the precipitation of casein curds, but has the disadvantage of being 
constipating. When protein indigestion causes watery brown st<x>l>, 
it is advisable to cut out the protein for a day or two, substituting 
carbohydrates in its place, and then restore the protein to the 
mixture. In addition to dietetic regulation an initial purge of 
castor oil should be given to sweep all of the large casein curds 
out of the gastro-intestinal tract. 

Feces. — The first stools after birth are of a dark and almost black 
color, and they remain so until the infant takes milk from the breast, 
after which they become yellow, are of a pasty consistency, and acid 
in reaction. If the infant is fed by the bottle the stools are lighter 
in color and larger in bulk than those of the breast-fed infant, but. 
as a rule, are fewer in number, the normal nursling Inning two to five 
stools a day. Curds found in the infant stool may be composed either 
of fat or protein (casein), the former being soft, and soluble in ether, 
whereas casein curds are hard, tough, usually larger than fat curds. 
and insoluble in ether. Green stools often cause the mother great 
concern; but, if the bowel discharges are otherwise normal, this 
change is of no significance, being due to the conversion of bilirubin 
into biliverdin. White and gray stools indicate the presence of fats 
in the form of soap and the absence of bile. Black stools are usually 
caused by the ingestion of drugs, such as iron, bismuth subnitrate or 
charcoal; but, in rare instances, the presence of blood from the intes- 
tinal tract gives the discharges a black, tarry color. If bright scarlet 
blood appears in the stool, its origin is an anal fissure or rectal polyp. 

Pus in the discharges indicates some severe inflammation of the 
intestines; and, while a small quantity of mucus may be found hi 
the normal stool with the aid of a microscope, a considerable amount 
is abnormal and signifies intestinal inflammation. There is only a 
faint odor to the stools of breast-fed infants, while in those of the 
bottle-fed baby it may be quite pronounced, and varies according 
18 



274 DISEASES OF THE GASTRO-INTESTINAL TRACT 

to the diet. The stools in fat indigestion are loose and contain fat 
curds and fat in the form of soap. If the infant receives too little 
of fats the stools become dry and hard. Casein curds are characteristic 
of protein indigestion, and the stools are usually increased in number, 
alkaline in reaction, with a decidedly fecal odor. Thin, watery, 
highly acid stools, which irritate the buttocks and genitalia, are 
characteristic of sugar indigestion. At the present time the bacterio- 
logical examination of infants' stools is of little clinical value, owing 
to our limited knowledge of the relation of bacteria to digestive dis- 
turbance and inflammation of the intestines. 

Acute Gastric Indigestion. — Acute gastric indigestion is one of the 
most common affections of infancy and childhood. 

Etiology. — Improper feeding, whether irregularity of the feeding 
periods or an excessive amount of food, is most frequently the cause 
of gastric indigestion in infancy; but a change of diet, if too radical, 
will often bring on a severe attack of indigestion, while occasionally 
a diet, which up to a certain period has been perfectly suitable, will 
overtax the stomach because an existing illness has lowered the power 
of digestion. 

Artificially fed infants furnish the majority of cases, for rarely is 
there change enough in breast milk, from nervous excitement or any 
other cause in the mother, to make it indigestible; but a protracted 
spell of hot weather, or the substitution of a prepared food or cow's 
milk for one nursing period, will often produce a severe attack of 
gastric indigestion in an otherwise healthy breast-fed infant. In 
artificially fed babies the attack is brought on by either the poor 
quality of the food given or the strength of the preparation. Older 
children suffer from acute gastric indigestion because of indulgence 
in pastry, candies, unripe fruits, and other indigestible articles, and 
by eating continually between meals or too hurriedly at table. The 
disease is most prevalent during the summer months, and frequently 
occurs, during the period of dentition. 

Symptoms. — The principal symptoms of acute gastric indigestion 
are pain referred to the hypochondrium, vomiting, nausea, headache, 
and fever. Preceding these acute symptoms there is usually a period 
of malaise during which the child is tired, peevish, and shows no desire 
to play. Vomiting is accompanied by much retching. The vomitus 
is sour, and composed of undigested food. The stomach is generally 
somewhat distended. In severe cases the child may be prostrated. 
The temperature may rise to 104° F. or above. Convulsions some- 
times occur. The pulse becomes weak and rapid. There may be an 
occasional chill. The breath is always foul, the tongue thickly coated. 
An attack such as this is usually preceded by constipation, but may 
be followed by diarrhea. For a few days afterward the stomach is 
very sensitive, and unless extreme care is exercised nausea and vomit- 
ing may again occur. 

Diagnosis.— The diagnosis of acute gastric indigestion is usually 
a simple matter because of its frequency in childhood; but one should 



ACUTE GASTRITIS 275 

always remember that the gastric disturbance may be merely a 
symptom of one of the acute infectious diseases. 

Prognosis. — Recovery, as a rule, promptly follows the removal 
of the cause, and rarely does a case terminate fatally if properly 
treated at the onset. Occasionally a convulsion will occur which, in 
a very weak infant or child, may prove fatal. 

Treatment. — In every case the stomach should be emptied as quickly 
as possible with the aid of a stomach-tube or by the administration 
of an emetic. Stomach washing is accomplished in infants by passing 
a small catheter (No. 16 American) into the baby's stomach while 
the child is held in an upright position, after which it may be laid on 
the nurse's lap on its side. A glass connecting rod with rubber tubing 
and a funnel at the distal end is attached to the catheter, and warm 
water or salt solution poured into the funnel, and subsequently 
siphoned off. This is done repeatedly until the water returned from 
the stomach is perfectly clear. In older children it is so difficult to 
pass a stomach-tube that this procedure is not often attempted; 
but they should be compelled to drink glass after glass of warm water 
and to take one or two drams of the syrup of ipecac. 

Once the stomach is emptied, nothing should be taken by mouth 
for some hours (twelve to twenty-four) with the exception of a 
little water. Calomel is, perhaps, the best drug we can use, and this 
may be given in grain doses, corresponding to the age of the child up 
to five years. When nausea disappears albumen-water, barley-water, 
or whey may be given cautiously in small quantities for twenty-four 
hours, after which the breast-fed infant may be put to the breast for 
a nursing period of not more than five minutes every three hours 
for the following day or two, gradually increasing the length of this 
period until the normal amount of food is being taken. 

The somewhat older infant may be given weak broths on the second 
day, and gruels or light semisolids following this, according to the 
improvement noted. Constipation is usually relieved by the calomel 
given; but, should it persist, a tablespoonful of milk of magnesia, or a 
half-glass of magnesium citrate, may be. given a child of three years, 
or a soapsuds enema or glycerin suppository may be resorted to. 



ACUTE GASTRITIS. 

Acute gastritis is an acute inflammatory condition of the stomach 
which rarely occurs primarily, but is seen frequently during childhood 
accompanying that common disease, gastro-enteritis. The line of 
demarcation between severe acute gastric indigestion and acute gas- 
tritis is very obscure; but in acute gastritis we assume that there are 
lesions of the stomach, however slight, and we also recognize five 
types of this affection; i. r., catarrhal, membranous, toxic, ulcerative, 
and suppurative. All but the catarrhal form, however, are so rare 
that thev need onlv to be mentioned as definite clinical entities. 



270 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

Etiology. — The most frequent causes of acute gastritis are improper 
food, too frequent or too hasty eating, or any of the other factors 
active in the causation of acute gastric or gastro-intestinal indiges- 
tion. It is often observed during the course of the acute infectious 
diseases, and occurs secondarily in many inflammatory states of the 
intestinal tract. The most severe form of acute gastritis is that 
which results from the ingestion of strong acids or alkalies. 

Pathology. — In catarrhal gastritis the gross changes are not marked, 
but the gastric mucosa in certain areas is reddened and swollen, 
while the stomach is either contracted or dilated, and contains undi- 
gested food and great quantities of mucus which may be blood-stained 
from slight hemorrhages. Microscopically, patches of mucosa are 
seen to be infiltrated with round cells, and there are numerous erosions 
of the epithelium with minute extravasations of blood scattered over 
the mucosa. 

The gastritis produced by corrosives or acids is characterized by 
large ulcerated areas denuded entirely of mucous membrane, though 
but rarely does the ulcer penetrate the stomach wall. In membranous 
gastritis a false membrane forms on the lining of the stomach, the 
cause of which is either the diphtheria or pseudodiphtheria bacillus. 
Ulcerative gastritis is merely an inflammation of the gastric mucosa, 
characterized by the formation of numerous small erosions or ulcera- 
tions. If pus be present in the stomach wall the condition is known 
as suppurative gastritis, but this is very rare. 

Symptoms. — At the onset of the disease the symptoms of acute 
catarrhal gastritis differ from those of acute gastric indigestion only 
in the degree of severity. Vomiting is decidedly worse, and may 
persist for several days or even a week. The vomitus is at first com- 
posed of undigested food, but later consists of mucus tinged with bile 
or even blood. There is a sudden rise of temperature to 104° or 105° 
F., which is significant of rapid absorption of toxins, while pain may 
be so severe that, in addition to rigidity of the abdominal muscles, the 
muscles of the legs are contracted and fixed, drawing the thighs up 
toward the abdomen. The belly is visibly distended, and so tender 
that the child protests by screaming if any attempt be made to 
palpate it. The pulse is accelerated, and ranges between 140 and 160, 
the respiratory rate also being increased. Thirst is extreme and hard 
to relieve; the mouth is dry; the tongue heavily coated; the breath 
has a fetid odor. 

In severe cases convulsions may occur at the onset of the attack; 
but, if vomiting continues, exhaustion sets in and the child may become 
prostrated. Constipation usually precedes the attack, but many 
times there is diarrhea, numerous foul-smelling, semiformed stools 
being passed daily. The urine throughout an attack of acute gastritis 
is scanty, high-colored, acid, and concentrated owing to the loss of 
body fluids through other channels. 

Suppurative gastritis is characterized by the same symptoms, 
although it is usually of longer duration. 



ACUTE GASTRITIS 277 

Membranous gastritis can be diagnosed only after death, since 
the symptoms are not characteristic, and the affection is such a 
rarity as to afford no opportunity for its study. 

The symptoms of ulcerative gastritis are much the same as in the 
acute catarrhal form, but the former is marked by more hemorrhages 
from the mucous membrane of the stomach. 

Acute gastritis not infrequently extends info the duodenum, which 
is indicated by the appearance of jaundice, especially in older children. 

Diagnosis. — Acute gastritis is only to be differentiated from acute 
gastric indigestion by the severity and persistence of the symptoms. 
Close observation for several days is also necessary before one can 
definitely say that the gastric disturbance is not merely the beginning 
of one of the acute infections. Meningitis is often closely simulated 
by acute gastritis; but in meningitis the pulse rate is slow, while in 
acute gastritis it is accelerated, and this differential point, together 
with the local signs and symptoms in acute gastritis, should make 
the correct diagnosis easy. Pneumonia is sometimes suggested; but 
careful examination of the chest will fail to elicit any physical sign 
of this disease; while if typhoid fever be suspected abdominal exam- 
ination will reveal neither the enlarged spleen and liver nor the typical 
rose spots, and a Widal test will verify these negative findings. A 
valuable aid in the diagnosis of acute gastritis is an accurately taken 
history in which particular attention is directed to the nature of the 
child's diet. 

Course and Prognosis. — The usual duration of an attack of acute 
catarrhal gastritis is fiom several days to a week, after which time 
the infant or child who has previously enjoyed good health will have 
an uneventful recovery. On the contrary, in weak, marasmic infants 
and poorlv nourished, anemic children, acute gastritis sometimes 
proves quickly fatal or, more often, shows a tendency to become 
chronic, and the patient gradually so loses weight and strength that 
it easily succumbs to some slight infection. 

Treatment. — This differs but little from the treatment of acute 
gastric indigestion. The stomach should be emptied immediately, 
and as long as vomiting persists the best way to accomplish this is 
either to wash the stomach out in the way described under the treat- 
ment of acute gastric indigestion, or, if this is impossible, as is usually 
the case in older children, emesis should be secured by administering 
1 or 2 drams of syrup of ipecac and then compelling the child to 
drink glass after glass of warm salt solution. 

Purgation should be produced if possible, and 1 grain of calomel 
given to infants in y^-grain tablets every half-hour, or 2 grains of calo- 
mel given in f-grain doses to older children, if followed by a purgative 
dose of magnesium sulphate, is an excellent therapeutic aid in treat- 
ment. Nothing but this medicine should be put in the stomach for 
from twenty-four to forty-eight horns. If thirst is extreme small 
bits of ice or sips of cold water may be given the child. 

The symptoms of acute gastritis rarely require special attention; 



278 DISEASES OF THE GASTRO-INTESTWAL TRACT 



but if fever runs high the child may be sponged with tepid water, and 
if convulsions appear it should be put in a warm bath. Children and 
infants in poor physical condition occasionally require stimulation 
by means of the hypodermic administration of camphorated oil, 
1 drop for each year of the child's age. Aromatic spirits of ammonia, 
10 to 40 drops, diluted with water, if retained when given by the 
mouth, is often followed by marked stimulation. If oral adminis- 
tration of drugs be impossible, an ounce of black coffee may be given 
by rectum. If vomiting persists, cerium oxalate in J-grain doses, 
combined with bismuth subnitrate, gr. x, should be administered 
every three hours, this dosage being suitable for a child of three years. 
The stomach should be washed out two or three times daily. 

After the active symptoms have subsided and nausea has ceased, 
feeding may be very gradually resumed. For the first day or so after 
a period of starvation, the breast-fed infant may be allowed a nursing 
period of at first three minutes, and later five minutes, every four 
hours, each nursing to be preceded by the administration of two or 
three ounces of sweetened water to dilute the milk. If improvement 
continues, and the baby seems unsatisfied, the nursing periods may 
be gradually lengthened until the child gets the normal quantity of 
breast milk at each feeding. 

Artificially fed infants should be deprived of milk for even a longer 
period — barley-water, albumen-water, rice-water, or whey taking the 
place of the usual formula for several days, or until the stomach can 
again retain food, when a little milk may be added to these prepara- 
tions, increasing the amount at each feeding until the full quota is 
being taken. If, while milk is being given, any symptoms of gastritis 
appear, the milk should be immediately stopped. Lime-water is an 
excellent diluent for milk in such cases, and if milk or cane sugar is 
not borne well by the stomach, saccharin or glycerin may be added 
to the formula to make it palatable. 

Older children should be kept on gruels and broths for the first day 
or so after it is deemed advisable to begin feeding, and if the stomach 
continues to improve, junket, jellies, stewed fruits, and other semi- 
solid foods should be given, gradually increasing the strength of the 
nourishment, until the child is again on full diet. Tincture of nux 
vomica is sometimes a great aid to digestion in these children, and 
may be given in three minim doses three times a day combined, 
for a child of five years, with dilute hydrochloric acid in 5-minim 
doses. 

In the treatment of corrosive gastritis, much the same procedure 
is carried out, except that the stomach-tube should never be passed 
because of the danger of perforation. An antidote should be given 
immediately, and emesis must be secured by forcing the patient to 
drink excessive quantities of warm water until vomiting ensues, and 
the water returns clear from the stomach. Morphine is required for 
the relief of pain, and when nourishment is craved nothing should be 
given by mouth but oils and milk. Stimulants such as are prescribed 



ACUTE GA8TRd-ENTERlT18— SUMMER DlARkHEA 279 

under the treatment of acute catarrhal gastritis arc even more acces- 
sary, hut in corrosive gastritis are often useless, since, if much of the 
poison has been swallowed, no treatment available will prevent a 
fatal termination. 

GASTRODUODENITIS. 

Gastroduodenitis occurs commonly as a result of the extension of 
acute catarrhal inflammation of the stomach into the duodenum, 
causing jaundice by involvement of the bile ducts. It is usually 
most alarming to the parents, but is not regarded as a serious compli- 
cation of gastritis. 

Symptoms. — The symptoms of acute catarrhal gastritis vary little 
with involvement of the duodenum. Jaundice is the most prominent 
feature. The stools are clay-colored, the bowels constipated. The 
urine is stained with bile. On examination of the abdomen, the liver 
is usually found to be enlarged. 

Treatment. — The diet should be restricted to Liquids. The infant 
may be given whey, albumen-water, or barley-water instead of milk, 
while the older child should take only broths and diluted milk until 
improvement is noted. Cholagogues are indicated in gastroduodenitis, 
and there are several which may be used with equally good results. 
The phosphate of soda may be given daily in from 10- to 30-grain 
doses to either infant or child, or podophyllum may be administered 
twice daily in from y-g-- to J-grain doses, according to the age of the 
patient. Under careful treatment the jaundice should disappear in 
the course of three to ten days. 

ACUTE GASTRO-ENTERITIS— SUMMER DIARRHEA— SUMMER 

COMPLAINT. 

Acute gastro-enteritis is the most common form of infectious diar- 
rhea met with in children. It may be caused by either the dysentery 
bacillus of Shiga and Flexner, the streptococcus, the colon bacillus, 
the Bacillus pyocyaneus, or the gas bacillus. The disease differs from 
ordinary diarrhea with fermentation in that the bacteria are found 
in the walls of the intestines where they may produce lesions, while 
in fermentative indigestion bacterial activity is confined to the intes- 
tinal contents. 

Etiology. — Acute gastro-enteritis has been aptly termed "summer 
complaint' ' because of its prevalence in hot weather, a fact explained 
by the lowered vitality of infants in hot weather, and by the readiness 
with which milk and other foods become contaminated and spoil at 
this season. 

Digestion also is inhibited to such a degree in hot weather that a 
feeding mixture, which might be perfectly suited to an infant's diges- 
tive powers in cooler weather, is too strong for summer feeding, and 
must be reduced lest it cause gastro-enteritis. 

It can be readily understood that if correct feeding for winter, 



280 DISEASES OF THE GASTRO-INTESTINAL TRACT 

when kept up until hot weather, may cause summer diarrhea, inju- 
dicious feeding, whether the fault be overfeeding, irregular hours, or 
carelessness in mixing the food, is also an important factor in its 
causation. 

Bottle-fed babies are the chief sufferers, but the disease is not 
extremely rare in summer in nursing infants who are kept too much 
at the breast. This is usually because the mother allows the infant 
to nurse whenever it is fretful, under the impression that it is hungry, 
when in reality it is thirsty and requires, not breast milk, but water. 

Mother's milk is practically sterile, but the artificially fed infant 
must take a milk which is often contaminated and, even though 
sterilized, may contain toxins generated by bacteria or introduced into 
the milk through poisonous weeds the cow has eaten. 

In institutions epidemics occur even among breast-fed infants, so 
that the possibility of direct contagion must be recognized, although 
it is probably a potent factor only in the production of summer diarrhea 
when children are closely segregated, being transmitted by means of 
soiled diapers, wash rags, towels, etc. When, however, all the children 
in a ward contract the disease simultaneously, the cause is most likely 
to be found in some unfit article of food. 

The children of the poorer classes are especially prone to the disease, 
its frequency and severity diminishing with improvement in hygiene 
and environment. Overcrowding and poor food account in large 
measure for the number of cases in tenement houses and congested 
districts. Age is also a predisposing factor, since the majority of cases 
are seen in children less than two years old, probably, and chiefly, 
because of injudicious feeding at this time of life. 

Pathology. — In many instances there is nothing characteristic in the 
appearance of the stomach and intestines, and, even when present, 
the lesions are varied and fail to correspond exactly with the nature 
and severity of the symptoms. As a rule, the duodenum and jejunum 
show no pathological lesions, but in the colon and the distal end of 
the ileum there may be evidences of catarrhal inflammation through- 
out the mucosa, with here and there a congested area, superficial 
erosion, or ulceration. There is an excessive outpouring of mucus 
which bathes the mucous membrane, while the solitary follicles and 
Peyer's patches are hyperplastic, or in some instances ulcerated. 

As a rule, the lesions are most marked in the large intestine, and 
almost invariably there is hyperplasia of the mesenteric lymph nodes. 
The stomach and intestines are dilated, distended with gas, and con- 
tain undigested food and mucus. 

Microscopic examination of the mucous membrane shows that the 
epithelium is degenerating and desquamating, and bacteria may be 
detected under the epithelial layers. A pseudomembrane sometimes 
forms and covers a considerable area. The changes in the viscera 
comprise cloudy swelling of the renal tubular epithelium, fatty degen- 
eration of the hepatic cells, and degenerative changes in the cells 
of the nerve centres. 



ACUTE GASTRO-ENTERITIS— SUMMER DIARRHEA 281 

Symptoms.- In mild cases of summer diarrhea, the child lias mod- 
erate fever, passes three or four loose curdy greenish-yellow stools 
a day, and may vomit several times daily after feeding. As a rule, 
it is restless and irritable, and may occasionally cry out with colicky 
pain. There is no desire for food, yet the child shows no prostration, 
and at no time seems seriously ill. 

This type of the disease, however, is not so grave as the usual 
acute form, which presents a far different picture. The onset is quite 
sudden, and is marked by persistent vomiting and frequent bowel 
movements which at first consist of fecal matter, but subsequently 
contain mucus and blood, and little else. The stomach may or may 
not reject food; but the appetite is so impaired that there is rapid 
emaciation. There may be severe pain, caused by the distention of 
the abdomen and the gas and tenesmus which accompany each bowel 
movement. The temperature range is from 103° to 105° F. at the 
onset of the attack, but may drop to 100° or 101° F. after several days 
of diarrhea. 

The infant is prostrated, restless, gets but little sleep, and takes 
practically no nourishment. Moreover, as a result of the constant 
straining at stool, it may suffer from prolapse of the rectum. The 
buttocks become excoriated, the thighs may be eczematous because 
of the irritation of the frequent bowel movements, which may aggre- 
gate from fifteen to twenty-five a day. 

The heart may also show signs of weakening and the pulse become 
feeble; but unless the infant is in poor physical condition at the onset 
because of malnutrition, rachitis, pertussis, or other constitutional 
devitalizing disease, death does not ensue except in the very severe or 
neglected cases. If the child is going to recover, a gradual amelioration 
in the severity of the symptoms is noticed, the stools decrease from 
twenty to ten daily, and contain less mucus and more fecal matter. 
Vomiting, if persistent during the attack, gradually diminishes in 
frequency and severity, and the stomach may retain a little light 
nourishment. In fatal cases the diarrhea continues; the stools contain 
nothing but mucus and blood; the high temperature and extreme 
prostration indicate severe toxemia; and death follows from con- 
vulsions and coma or exhaustion. 

In some cases neither death nor recovery ensues immediately, but 
the acute gastro-enteritis passes into a subacute stage, with cessation 
of vomiting, moderately copious diarrhea, mucus stools, and steady 
loss of weight. There may or may not be colic. 

The infant is usually very restless or apathetic. The abdomen is 
sunken or, in rare cases, distended; the spleen and liver are enlarged; 
the heart sounds are weak; albuminuria is usually present, and is 
due in most instances to cloudy swelling of the tubular epithelium 
since acute nephritis is rare. The blood, as a rule, shows a leuko- 
cytosis of 15,000 to 20,000, with a decided increase in the polynuclear 
leukocytes; in severe cases these figures may be much higher unless 
the system is too weak to react, and then leukopenia is present. 



282 DISEASES OF THE GASTRO-INTESTINAL TRACT. ' 

Holt describes an acute intestinal intoxication in which there is no 
diarrhea but, on the contrary, the child is constipated. To quote 
from his article: 

"These cases are puzzling and frequently most serious, but for- 
tunately they are not of common occurrence. I have, however, seen 
several striking examples with very high temperature, grave nervous 
symptoms, and sometimes marked abdominal distention, in which 
it seemed almost impossible to move the bowels by drugs. Castor 
oil, calomel, and salines have in some cases been tried in succession 
in four or five times the ordinary doses without the slightest effect, 
even when supplemented by frequent intestinal irrigation. It has 
sometimes been nearly two days before free movements were finally 
produced. These are often exceedingly foul. It is somewhat diffi- 
cult to explain such cases. There seems to exist for the time almost 
complete intestinal paralysis. The toxic materials are locked up in 
the small intestine, for the colon is frequently quite empty." 

Diagnosis. — The diagnosis of acute gastro-enteritis is not difficult, 
especially in those cases which occur during the summer months; 
but the differentiation between this disease and acute intestinal 
indigestion, or ileocolitis, can be made only after several days' study 
of a case, since at the onset the three diseases present like symptoms. 
The severity of the symptoms in acute infectious diarrhea is, perhaps, 
the most significant differentiating point between that disease and 
acute indigestion. 

On the other hand, if the symptoms become aggravated and there 
is pain with persistent high temperature after several days of diarrhea, 
ileocolitis is suggested rather than summer complaint. Since the 
exanthemata are frequently ushered in by premonitory diarrhea and 
vomiting, one should always reserve the diagnosis of infectious diarrhea 
until several days have elapsed without the appearance of a rash. 
A careful examination of the chest should be made for physical signs 
of pneumonia, and of the abdomen for rose spots and enlargement of 
the spleen, since in both typhoid and pneumonia diarrhea may be 
the predominant initial symptom. 

In severe cases of infectious diarrhea there may be distinct signs of 
meningeal irritation from toxemia; consequently, in meningitis with 
diarrhea the diagnosis of the meningeal condition should be made only 
tentatively until the diarrhea has subsided. 

Course and Prognosis. — An infant previously healthy, attacked by 
a mild summer diarrhea, usually puts forth its powers of resistance, 
and recovery follows in the course of a week or so; but acute gastro- 
enteritis yields a high mortality rate among the weak, anemic, poorly- 
nourished children of the slums. In severe cases the outcome depends 
to a large extent upon the physical condition of the child; but the 
presence or absence of complications, such as nephritis, broncho- 
pneumonia, or ulceration of the intestines, also affects the chances 
of recovery. In a favorable case the active symptoms should subside 
within a week, but diarrhea may persist for a month. The prospect 



ACUTE GASTRO-ENTERITIS— SUMMEJR blARRHEA 283 

of recovery is also greatly promoted by instituting proper treatment 
immediately, and removing the child from its crowded, unhygienic 

surroundings to the seashore or country. In the fatal eases death 
usually supervenes between the seventh and fourteenth days. Many 
of the chronic eases die. 

Treatment. — Prophylaxis has done far more to reduce the mortality 
in infants during the summer than we may ever hope to accomplish 
by the most skilful treatment; therefore a thorough understanding 
of preventive measures against summer diarrhea is of more vital 
importance than the actual management of a case.. 

The breast-fed infant should, if possible, never be weaned during 
the summer months. On the contrary, the mother should continue 
to nurse her baby, and with strict regularity as to intervals. Par- 
ticular attention should be paid to this phase of nursing in the summer, 
for, owing to the hot weather, the infant is constantly fretting from 
thirst, but is too often given the breast instead because the mother 
believes it to be hungry. In this way the amount of food is increased 
during the hot weather instead of diminished, as it should be, and 
gastro-intestinal disturbances result. Water that has been boiled 
should be given freely, and if this be done the number of feedings may 
be decreased during the summer months. 

The breasts should be kept perfectly clean, and the nipples cleansed 
before and after each feeding with boric acid solution. The baby's 
mouth may be kept clean by giving after each nursing a spoonful of 
boiled water. 

Fissured nipples and caked breasts are a potential source of infec- 
tion, and warrant the removal of the infant from the breast until the 
condition is relieved. These few precautions, together with the 
hygienic measures outlined below, will serve to protect the breast-fed 
infant from summer diarrhea. 

Far greater care must be exercised to insure the safety of the bottle- 
fed infant during the hot summer months. In the first place, the purity 
of the milk should be guaranteed, and, if possible, but a few hours 
should elapse between the milking period and the time the milk is 
used. Regardless of its purity, if the farm is located at a considerable 
distance from the consumer, the milk should be either pasteurized or 
sterilized at home before using it for the infant, and, as many babies 
are taken to the mountains, country, or seashore in summer, it is often 
necessary to do this with the milk. 

Cleanliness of the nursing bottle is also absolutely essential. It 
should be washed thoroughly with a bottle brush after each using. 
The nipples must be boiled each day, and kept in a saturated solution 
of boric acid until needed for use. It is well to decrease the quantity 
of each feeding by about one-half in real hot weather, and the strength 
of the formula may also be reduced to considerably below the standard 
for a normal infant. As a general rule, the less frequent the feedings 
the better the infant's digestion, and in the summer, particularly, 
three- or four-hour intervals between feedings are sometimes advisable. 



284 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

The child's clothing and body should also be kept absolutely clean, 
and a bath given once or twice daily. It should be kept out of doors 
in a cool place all day long, but direct exposure to the sun is very 
dangerous, and must be avoided. At night it should sleep in a cool, 
well-ventilated room, and be well protected against drafts. When- 
ever possible young children and infants should be sent away to the 
seashore or mountains for the summer months, preferably to coast 
resorts because of their equable climate. 

The stools of these infants should be carefully disinfected with 5 
per cent, carbolic acid solution before being disposed of, and the 
diapers thoroughly washed and disinfected before using them the 
second time. Better still is a cheap napkin that can be destroyed 
after use. Cleanliness on the part of the mother or nurse is essential 
to prevent contamination of the food by her hands, since reinfection 
from this source may happen. 

Every case of diarrhea or digestive disturbance occurring in babies 
during the summer must be considered serious, and prompt measures 
taken for its cure. Feeding must be stopped at once, and a purgative, 
preferably castor oil, should be administered. Milk, especially, should 
be withheld for several days, even from the breast-fed infant, and for 
the first twenty-four to forty-eight hours nothing but boiled water 
given. This can be taken as frequently as desired. If improvement 
is noted on the second day, and the infant seems hungry, weak barley- 
water or albumen-water may be given, one or two ounces at a time 
every three hours for a day or so, after which breast feeding may be 
resumed. The baby should nurse for only three to five minutes at 
first, and there should be an interval of three or four hours between 
the feedings. If improvement continues, the length of the nursing 
period may be gradually increased until the child nurses full time. 
If, on the other hand, the symptoms grow worse when the infant is 
put to the breast, nursing should again be stopped for several days, 
when another attempt at breast feeding may be made. 

The artificially fed infant may be deprived of food for an even 
longer time than the nursling, and if there are no visible signs of 
improvement, all nourishment, especially milk, may be withheld 
for several days or even a week, and nothing but albumen-water or 
w^eak barley-water permitted. Water may alw r ays be given freely, 
but barley-water and egg albumen should be allowed only when the 
stomach becomes retentive, and then in one-half the usual amount 
for a child of a given age. 

The strength of the food must be increased cautiously, and it is 
well to keep the child on weak broths, beef juice, rice-water, barley- 
water, or predigested preparations for a week or more before attempt- 
ing to give milk. Eiweiss milk is very well borne in some cases; 
skimmed milk, well diluted, may be tried at first; but no attempt should 
be made to give milk until the stools show their normal characteristics. 

A good way in w T hich to resume milk feeding is to add a teaspoonful 
of milk to each feeding; then, if no untoward symptoms develop 



ACUTE CASTRO-ENTERITIS— SUMMER DIARRHEA 285 

gradually to increase the amount of milk until a formula may be given. 
The strength of this formula, however, should be much below that 
given to the same child when well, and only one-half the usual quan- 
tity should be allowed at a feeding. If a whey-cream mixture is well 
borne, this may be given with barley-water or rice-water and sugar 
of milk. It is generally advisable to peptonize the milk in order to 
insure its assimilation; for malnutrition is usually extreme, and the 
prognosis frequently depends upon the infant's ability to utilize its 
nourishment. 

Recent investigations have shown that if the infectious organism 
is the colon bacillus, the Bacillus dysenteric, or the streptococcus, a 
carbohydrate diet will aid in effecting a cure, while a protein, fat-free 
food is more beneficial when the diarrhea is caused by the gas bacillus 
and its allied organisms. Further laboratory investigations are neces- 
sary before these finer points in dietetic management can be applied. 
In particularly stubborn cases where attempts at feeding are ineffec- 
tual, dextrinized cereals and preparations, such as Keller's malt 
soup, offer nourishment in the form easily digested and assimilated. 
Better still, an effort should be made to secure a wet-nurse, since breast 
milk is the most easily digested and highly nutritious food the infant 
can take. 

In no case should the strength or quantity of the food be increased 
rapidly, owing to the danger of relapse. Reinfection can only be 
avoided by careful after-treatment and strict regulation of the diet. 
In feeding children during the summer it is a good rule never to give 
them as much as they desire, and never to encourage them to eat 
when they display no appetite. 

Hygienic Management. — Next in importance to the dietetic treat- 
ment of acute gastro-enteritis is its hygienic management. The child 
should be kept in the open air, if possible, or in a cool room which 
is sunny and well ventilated. The clothing should be very scanty, 
and in extremely hot weather a diaper is all that is necessary. A bath 
should be given at least once or, better, twice a day. The buttocks 
and thighs should either be anointed with sterile vaselin or powdered 
with boric acid to prevent chafing and eczema from the irritation of 
the frequent stools. 

These hygienic measures, while essential and sometimes effectual 
in ameliorating summer diarrhea, should be carried out at home onlv 
when the child cannot be sent away; for immediate removal of the 
city child to seashore or mountains offers a far better chance for 
improvement than any hygienic measures employed at home. The 
nurse or mother should be instructed to observe the strictest cleanli- 
ness with regard to the child and its food and clothing in order that, 
once cured of the disease, reinfection does not occur. 

Symptomatic and Medicinal Treatment. — Of the acute symptoms 
vomiting and diarrhea often call for immediate relief. If the attack 
be especially severe, stimulation may be necessary. As a rule, vomit- 
ing is not exhausting, and ceases if food is withheld; but, if it per- 



286 DISEASES OF THE GASTRO-INTESTINAL TRACT 

sists, the stomach should be washed out with warm saline solution. 
It is scarcely ever necessary to repeat this procedure, since one wash- 
ing not only checks vomiting but cuts short the attack. If lavage is 
of no benefit emetics, such as warm mustard water in large quantities, 
or syrup of ipecac in |- to 1-dram doses, should be administered to 
evacuate the stomach. 

Since diarrhea, like vomiting, is a conservative process at the 
onset of acute gastro-enteritis, increased evacuation of the bowels 
should be promoted by the administration of a purgative to clean them 
out. Castor oil is probably the best drug for this purpose; but calo- 
mel or a saline may be amply effectual . The proper dose of castor 
oil would be 2 drams for an infant of six months, 4 drams for a one- 
year-old child, and an additional dram for each year of age above this. 
One grain of calomel is sufficient for the infant of one or two years, 
and may be given in to of a grain dose every hour. Magnesium 
citrate should be administered in dram doses diluted with water, 
while the sulphate of magnesium is retained best by the stomach if 
the usual dose of 1 dram is given, well diluted, and in small portions 
at frequent intervals. 

In addition to free catharsis, colonic irrigations are of great benefit 
in cleaning out the lower bowel, as well as in stimulating peristalsis 
and supplying fluid for absorption by the gut. They should be given 
daily, or even twice a day, at the onset of the attack, using a pint of 
normal salt solution for very young infants and a quart each time for 
older children. If tenesmus is severe, starch enemata may be used 
temporarily in place of the saline solution, and cocaine suppositories 
each containing J to \ grain may be inserted after the irrigation. 
Care should be taken that the temperature of the solution when used 
is at least one degree above that of the body; for, especially in weak 
infants, and if the fluid is cold, irrigation may be followed by marked 
depression and even collapse. When the stomach does not retain 
food, nutrient enemata may be given, and salt solution administered 
by slow proctoclysis. 

Despite the colonic irrigations it may become evident during the 
course of an attack that toxins are again being absorbed from the 
intestinal tract; and when this happens free purgation is again indi- 
cated. If stimulation is necessary, atropine sulphate and strychnine 
sulphate may be given in 4-9-0 to 2T0" of a grain dose hypodermically, 
or 1 to 5 minims of camphorated oil may be administered in the 
same manner. Alcohol in the form of brandy or whisky is also 
valuable if given in 10- to 30-drop doses every two hours when col- 
lapse seems imminent, but should not be used routinely in every 
case. Hypodermoclysis has been employed with success in cases of 
threatened collapse; but, unless great care is taken to prevent infec- 
tion by sterilizing the solution and apparatus used, an abscess may 
form at the site of injection and prove a serious complication. 

Hot baths are very stimulating, but the water must be hot enough 
to bring about a reaction yet, at the same time, not burn the patient. 



ACUTE ENTEROCOLITIS 287 

The child should not be allowed to remain in the water more than 
three to five minutes, and should be carefully protected from draughts 
after the bath. 

The use of drugs in summer diarrhea for other purposes than 
purgation and stimulation does not appreciably affect the course or 
duration of the disease; but the administration of such intestinal anti- 
septics as bismuth, salol, and resorcin is always advisable since they, 
at least, inhibit bacterial growth. To be effectual subnitrate of bis- 
muth must be given in 5- to 10-grain doses every two hours to a child 
from one to two years of age. Salol and sodium salicylate are less 
well borne by the stomach, but may be given in 1 -grain doses every 
two hours to infants of one year and over. Resorcin may cause vomit- 
ing; but if small doses of \ to 1 grain are administered every two or 
three hours to an infant one year old, the stomach may be able to 
retain it. Sulphur given in the same manner is equally effective and 
less liable to provoke vomiting. 

Because of its constipating effect, opium should never be used until 
the intestinal tract has been thoroughly purged, unless pain is so 
severe that collapse is threatened. Later in the course of summer 
diarrhea, when it becomes advisable to check the number of bowel 
movements, paregoric may be given once, twice, or oftener daily in 
5- to 10-drop doses to the child of one to two years; or Dover's 
powder, \ of a grain, in repeated doses every three hours until relieved. 
Morphine should be resorted to only when agonizing pain requires 
instant relief, and in these cases T V to 3V of a grain of the sulphate 
may be administered hypodermicallv. 

ACUTE ENTEROCOLITIS. 

Acute enterocolitis is an inflammation of the small and large intes- 
tines caused by the same factors which give rise to summer diarrhea, 
but differing from that disease pathologically in being sometimes 
accompanied by quite distinct ulcerations in the bowels. This affec- 
tion is also characterized by the passage of blood-streaked mucus 
stools with violent tenesmus, so that it may be mistaken for true 
dysentery. As a matter of fact, severe cases of acute enterocolitis 
cannot be differentiated from dysentery; but, as a rule, the symptoms 
are much milder. 

Etiology. — Acute enterocolitis is a disease of infancy, but few cases 
being seen in later childhood. It is most common among children of 
the poorer classes, hence improper food, unhygienic surroundings, 
lack of fresh air, uncleanliness, and segregation are evidently among 
the chief predisposing factors. The majority of cases occur during 
the summer months, and in children whose physical resistance has 
been impaired by an attack of acute gastro-enteritis or some other 
gastro-intestinal disturbance. Syphilis, tuberculosis, rachitis, and 
other chronic systemic conditions predispose a child to enterocolitis; 
in nianv instances we find a history of recent recover v from broncho- 



288 DISEASES OF THE GASTRO-INTESTINAL TRACT 

pneumonia or some acute contagious disease. Numerous investigators 
have found the colon bacillus, the streptococcus, and the bacillus of 
Shiga in large numbers in the stools of these cases; therefore we are 
justified in believing that acute enterocolitis is infectious in origin. " 

Pathology. — Two distinct types of acute enterocolitis are demon- 
strated by postmortem findings. In the catarrhal form the lesions 
are mild, and resemble those found in the intestines in cases of acute 
gastro-enteritis. The mucous membrane of the lower end of the 
ileum and the colon is swollen and hyperemic, while hemorrhagic 
areas may be scattered throughout. The lymphoid structures are 
swollen and elevated, and there is apt to be marked congestion of 
Peyer's patches. The gut has a rough feeling due to epithelial 
desquamation, and in the pseudomembranous form of enterocolitis 
a false membrane covers the mucosa. 

The ulcerative form is characterized by the formation of large 
and small ulcers, particularly in the large bowel. This usually occurs 
in children who are debilitated by preceding illness. Large ulcers 
are, as a rule, quite superficial; but the smaller ones are deep and may 
extend down to the muscular coat of the intestine. They are generally 
the result of involvement of the lymphoid follicles with subsequent 
ulceration and excavation. The most common lesions found asso- 
ciated at autopsy are those of bronchopneumonia. 

Symptoms. — The onset of acute enterocolitis is usually very sudden, 
the symptoms, for the most part, being referable to the intestines. 
The bowels are very loose, and as many as ten to fifteen greenish 
watery stools may be passed daily. Later the discharges are com- 
posed of mucus and blood, each movement being attended by great 
pain and tenesmus. Vomiting occurs only in severe cases, and in 
these prostration may come on quickly. The temperature is elevated, 
ranging from 103° to 105° F., the pulse is correspondingly rapid, and 
the respiratory rate accelerated. In mild cases the temperature drops 
to normal in a few days, vomiting ceases, the diarrhea subsides, and 
recovery takes place within ten days to two weeks from the onset. 
In severe cases, however, the inflammation may become chronic; 
or, if the child's resistance is very low, bronchopneumonia may set 
in as a dangerous, or even fatal complication. 

Diagnosis. — The diagnosis of acute enterocolitis is obvious from the 
frequent and painful bowel movements, and the presence of mucus 
and blood therein. Dysentery may be closely simulated, but in the 
ordinary case of acute enterocolitis is ruled out by the comparatively 
mild symptoms. Intussusception may be thought of in some cases; 
but abdominal palpation and rectal examination reveal no abdominal 
tumor, and the fever in acute enterocolitis is too high to be accounted 
for by intussusception. 

Prognosis. — Acute enterocolitis occurring in an infant previously 
healthy usually ends in recovery; but when it is secondary to a severe 
or wasting disease, or complicated by bronchopneumonia, the outlook 
is grave. 



DYSENTERY 289 

Treatment. — All feeding should be stopped immediately, and a 
purgative dose of castor oil given. If pain is severe it may be neces- 
sary to administer ^V to ^V of a grain of codeine sulphate, or 1 to 3 
drops of tincture of opium, every two or three hours. After twenty- 
four to forty-eight hours of starvation, an ounce or two of barley- 
water, rice-water, albumen-water, or weak broths should be given 
every two hours. Milk should be omitted from the diet for at least 
a week. After the bowels have been thoroughly evacuated, bismuth 
in full doses of 10 to 20 grains, according to age, should be adminis- 
tered frequently (every two or three hours) in order to control the 
diarrhea. When the number of stools has decreased considerably 
and other symptoms have subsided, boiled milk, at first in small 
quantities, may be added to the feeding mixture, and this amount 
cautiously increased as improvement is noted, until the child is again 
taking its full quota of milk. 

If the constitutional symptoms are severe and collapse threatens, 
stimulation may be required; and in these grave cases it is well to 
support the child by 10- to 30-drop doses of brandy every two hours, 
together with atropine sulphate, -g-J-g- to ^-g-g- of a grain, or strychnine 
sulphate, -g-g-g- to -s-g-g- of a grain, according to age. These children 
should be sent to the seashore or mountains as soon as convalescence 
is established, for, midst healthful surroundings, recovery is more 
rapid and relapses are much less apt to occur. 

DYSENTERY. 

Dysentery is an acute diarrheal affection of infancy and childhood, 
in most instances caused by bacterial invasion of the intestines, and 
occasionally by the Ameba coli. In the United States amebic dysen- 
tery is rare, but sporadic cases occur here and there throughout the 
country. It is highly probable that there are more cases of amebic 
dysentery among children in the southern states than is ordinarily 
presumed. 

Etiology. — In most cases of dysentery the essential etiological fac- 
tor is invasion of the gastro-intestinal tract by bacteria, of which the 
bacillus of Shiga and the organism isolated by Flexner are the most 
important. In this country the Shiga-Kruse bacillus is but rarely 
found in dysenteric stools, most cases being due to the Flexner bacillus, 
which is acid-forming, and does not ferment in milk or sugar media. 
Numerous organisms allied to the Flexner bacillus have been isolated 
and, no doubt, give rise to many of the milder attacks of diarrhea so 
prevalent in summer. It is probable that the colon bacillus and the 
streptococcus, when found in large numbers in the stools of children 
with dysentery, constitute a mixed infection. In temperate climates 
bacillary dysentery occurs most frequently during hot weather either 
in sporadic cases or in epidemics which affect children who are on a 
mixed diet. The amebic form is usually contracted by the ingestion 
of raw fruits and vegetables or is conveyed by contaminated water. 
19 



290 DISEASES OF THE GASTRO-INTESTINAL TRACT 

Pathology. — The intestinal lesions are confined to the lower portion 
of the ileum and the colon, and in every case the large bowel is most 
markedly affected. The changes produced vary greatly in character 
according to the virulence of the organism, the resistance of the 
patient, and the duration of the attack. In mild cases there is merely 
catarrhal inflammation with congestion of the mucosa, swelling of 
Peyer's patches and, occasionally, hemorrhages scattered throughout 
the mucous membrane. More rarely, similar changes may be observed 
in the stomach and, exceptionally, the small intestine bears the brunt 
of the disease, the villi being so swollen and edematous that they 
project above the surface of the mucosa. The entire mucous mem- 
brane is covered by a thick tenacious layer of mucus, sometimes 
resembling a pseudomembrane. In mild cases microscopic examina- 
tion reveals epithelial desquamation. In more severe types of catarrhal 
inflammation, superficial ulceration occurs. These ulcers are almost 
invariably found in the colon alone, and while they may cover con- 
siderable areas they rarely burrow below the mucosa. 

The follicular and ulcerative type of dysentery is marked by the 
formation of small, punched-out ulcers at the site of the lymph nodules 
and solitary follicles. They are caused by necrosis of the nodule and 
evacuation of the softened and disintegrated tissue into the intestine. 
In some cases larger ulcers are found, formed by the coalescence of 
several small ones. Follicular ulceration frequently extends to the 
muscular coat, but perforation is a rarity; as a rule, the wall of the 
intestine becomes greatly thickened, and presents a worm-eaten 
appearance because of the ulcerated areas. In the more severe cases 
the mesenteric glands are congested and swollen, but there is no 
necrosis. In some instances the spleen is enlarged, while in the amebic 
form abscess of the liver is occasionally observed. Bronchopneumonia 
is a frequent complication, and urinary examination may reveal a 
mild nephritis or, even more probable, acute degeneration of the renal 
epithelium. 

Symptoms. — An attack of dysentery usually comes on suddenly 
with diarrhea as the most prominent symptom. This may be preceded 
by a feeling of malaise, with headache and a rise in temperature. 
Most cases present the picture of acute indigestion for the first day or 
two, but vomiting is usually neither severe nor persistent. The stools 
are at first composed of fecal matter; but, after several such have 
been evacuated, they become watery and consist for the most part 
of mucus and blood. There may be as many as twenty or thirty move- 
ments daily, all accompanied by such pain and straining that prolapse 
of the rectum is not uncommon. Relaxation of the sphincter may 
also take place, and result in the almost continuous passage of small 
amounts of mucus and blood in which may be found shreds of epithe- 
lium resembling particles of washed raw meat. The abdomen is 
usually distended and tender, and abdominal pain intense. Loss 
of fluid from the tissues causes great thirst, a dry mouth, and highly 
concentrated urine. In the most severe forms prostration from the 



DYSENTERY 291 

overwhelming toxemia is alarming, and the child may die in collapse 
on the second or third day. There, is always more or less nervous 
depression and prostration, the degree depending upon the absorp- 
tion of toxins. The pulse is rapid and feeble, the feet and hands are 
cold, and convulsions may occur. Emaciation is rapid and out of 
all proportion to the duration of the attack. As a result of the poor 
state of the nutrition bedsores frequently develop in protracted cases. 

Amebic dysentery is characterized by the same symptoms as the 
bacillary form, but the attacks are milder and the disease tends to 
run a subacute course marked by periods of quiescence and exacer- 
bation. 

Diagnosis. — Dysentery must sometimes be differentiated from 
typhoid fever and intussusception, and in cases where nervous symp- 
toms predominate it may simulate meningitis. Typhoid fever may be 
ruled out by a Widal test and by examination of the abdomen for rose 
spots and an enlarged spleen. The absence of abdominal tumor on 
palpation and rectal examination and the high fever we find in dysen- 
tery, serve to exclude intussusception. The diagnosis of dysentery 
is based upon the number of stools, tenesmus and straining at stool, 
and the passage of blood and mucus. Microscopical examination 
will reveal the infecting bacteria or the ameba coli. 

Course and Duration.— The usual duration of an attack of dysentery 
is from tw T o to three weeks, but recovery has been known to occur 
within ten days. In fatal cases, as a rule, death supervenes in the 
third w r eek, although very severe ones may succumb in a few days. 
When recovery is about to take place, the diarrhea lessens at the 
end of the first week, the stools become less watery, and no longer 
contain blood. Amebic colitis is characterized by its chronicity, 
and may persist for a year or longer. 

Complications. — Perforation of the intestines and peritonitis are 
extremely rare. In the amebic type of dysentery abscess of the liver 
and spleen may occur, but is most infrequent. There is usually 
evidence of acute degenerative processes in the heart, liver, and 
spleen. Bronchopneumonia, while a common occurrence in dysentery, 
should be regarded as an associated condition due to extreme inanition 
rather than as a complication. 

Prognosis. — The prognosis should always be guarded until after 
the first week or so of the attack. Healthy children, previously well 
nourished, usually recover, but the outlook is serious, if there has 
been an antecedent gastro-enteritis. 

Treatment.— Prophylaxis is an important phase in the consideration 
of dysentery. It consists chiefly in the prevention of contamination 
of food and drink. During the prevalence of epidemics care should 
be exercised to prevent the infection of healthy children by attendants, 
and the patient's hands must be kept clean lest he reinfect himself. 

At the onset of the disease a full purgative dose of castor oil should 
be administered, and this supplemented by colonic irrigations of 
normal salt solution at a temperature of 100° F., given twice a day. 



292 DISEASES OF THE CASTRO-INTESTINAL TRACT 

If vomiting is severe the stomach must be washed out, and all food 
withheld for from twenty-four to forty-eight hours. Milk is not 
well borne in these cases, and for at least a week only barley-water, 
rice-water, albumen-water, or weak broths should be allowed. After 
the first few days one saline irrigation a day is sufficient, and even 
this should be discontinued as soon as possible because of its irritating 
effect upon the rectum. If there be ulceration of the bowel with much 
bleeding a mild astringent solution, such as tannic acid, 1 dram to 
a pint of water, or extract of hamamelis, a half -dram to a pint of water, 
should be used instead of the normal saline solution. 

Bismuth subnitrate is excellent to check the diarrhea after castor 
oil has had its effect, but must be given in 10- to 20-grain doses every 
two or three hours. Opium is indicated if abdominal pain and tenes- 
mus are severe, and may be administered in the form of Dover's 
powder, J to \ of a grain at a dose, or 1 to 5 drops of the deodorized 
tincture of opium may be injected into the rectum in a solution of 
starch. In giving opium care should be taken not to lock up the 
bowels or allow the child to become stuporous; and before repeating 
a dose the effect of that given previously should be noted. Hot 
applications, such as very mild mustard plasters or hot-water bags, 
placed over the abdomen, serve to relieve pain, and if collapse is 
threatened the child should be surrounded by hot-water bags and be 
kept well covered. Stimulation, when required, may be furnished by 
hypodermic injections of atropine sulphate, ■$%-$■ to 4-J--0 of a grain, 
strychnine sulphate in ^Stt to -2~o"o"-g ram doses, and 1 or 2 grains of 
camphor in oily solution. 

The hygienic care of infants and children suffering from dysentery 
is exceedingly important, and whenever possible a change of climate 
should be insisted upon, for the reason that under proper environment 
recovery takes place more quickly and relapses are not as liable to 
occur. Syrup of the iodide of iron is a valuable adjunct in the treat- 
ment of the secondary anemia which follows, and quite large doses 
(15 to 30 drops) may be given three times a day. In treating amebic 
dysentery, a fluid diet should be maintained for a longer period than 
is necessary when treating older children with the bacillary form of 
the disease, and a 1 to 1000 or a 1 to 500 solution of quinine should 
be used for irrigations instead of salt solution. 

CHOLERA INFANTUM. 

Cholera infantum is the gravest form of summer diarrhea; but, 
fortunately, is more rarely met with than acute gastro-enteritis. It 
is characterized by sudden onset, incessant vomiting, diarrhea and 
prostration. In a considerable proportion of cases it terminates 
fatally since its course is with difficulty influenced by treatment. 

Etiology. — Although German investigators have proven that faulty 
assimilation of fat and sugar will produce cholera infantum, other 
observers have recently demonstrated that large numbers of the 






CHOLERA INFANTUM 203 

bacillus of dysentery (Flexner), the colon bacillus, the streptococcus, 
the Bacillus pyocyaneus, or the Bacillus acidophilus, or several of 

these organisms in combination, are present in every case; hence, for 
the present, this malady must be considered infectious in nature. 
Cholera infantum is so often associated with the use of impure milk 
that we are forced to the conclusion that it is due to toxins generated 
by bacteria ingested with the milk, and that these are either liberated 
in the milk before it is taken into the system or formed by bacterial 
growth in the milk after it has reached the stomach or intestines. 

In further support of the theory that impure milk is the cause of 
the disease is the fact that it appears only in the summer, also its 
frequency in bottle-fed infants and its rarity in the breast-fed. 
Cholera infantum occurs almost exclusively in children under three 
years of age, and rarely attacks previously healthy babies, so that 
the majority of cases are seen in the marasmic, anemic weaklings of 
the' slums whose nutrition is reduced and health impaired by over- 
crowding, unhygienic surroundings, lack of fresh air. and unsuitable 
food. 

Pathology. — The postmortem findings are few and insignificant in 
comparison with the symptoms. At death emaciation is extreme; the 
abdomen is retracted, the eyes are sunken, the skin lies in folds; yet 
the gastrointestinal tract may show evidence of merely a catarrhal 
inflammation, with here and there minute hemorrhages and super- 
ficial erosions of the epithelium. The stomach and intestinal mucous 
membranes may either be hyperemic or have a washed-out appear- 
ance. Even upon microscopic examination they show nothing more 
than intense inflammation with epithelial desquamation. The liver 
cells reveal fatty degeneration, while the renal epithelium of the 
convoluted tubules is in a state of cloudy swelling. 

Degenerative changes are also detected in the heart muscle, while 
the lungs show areas of consolidation from collapse, also hypostatic 
pneumonia at their bases. Because of the great loss of body fluid 
which reduces the amount of serum, the blood is thick, concentrated, 
and dark red in color. 

Symptoms. — The onset of cholera infantum is Aery sudden. The 
disease is usually ushered in by a rise of temperature and prostration. 
quickly followed by violent and persistent vomiting and diarrhea. It 
generally appears in an infant who has been ill with a mild, subacute, 
or chronic digestive disturbance of such trivial nature as scarcely 
to cause the mother to seek medical advice, but cases have been 
reported in babies previously healthy. 

Vomiting usually precedes the diarrhea. At first the vomitus con- 
sists of undigested food and sour-smelling curds; later, bile and 
mucus are expelled. After this the vomitus is composed of a thin 
serous fluid containing flakes of mucus. Diarrhea is profuse at the 
onset, and after the intestinal contents are evacuated the stools 
become extremely watery. From twenty to thirty movements a day 
are not unusual; but when the tissues of the bodv are drained of fluid 



294 DISEASES OF THE GASTRO-INTESTINAL TRACT 

the stools become smaller. They have a peculiar, musty odor, and 
may be either yellow, greenish, or gray m color. 

The temperature is usually high at first, ranging from 103° to 10(3° 
F., but may drop to normal or subnormal from the loss of body heat. 
In some cases it rises to 107° or 108° F. at death. Thirst is intense, 
but appetite is completely lost, and food is refused. The pulse become 
rapid and feeble; the respirations are shallow. Prostration comes on 
quickly; the skin becomes cold and clammy; the eyes are sunken; 
the abdomen is retracted ; the anus is often so relaxed that the passage 
of intestinal contents is continuous. 

Delirium now sets in, and the infant either dies in convulsions or 
passes into stupor, finally into coma, and death supervenes. Loss 
of weight is so rapid and extensive that it may amount to 25 per cent, 
of the entire body substance in forty-eight hours. In a few cases the 
prostration is not so extreme, and the symptoms tend to subside 
after a day or so, but recovery is, unfortunately, not the rule. 

Diagnosis. — In cholera infantum the diagnosis is largely determined 
by the severity of the symptoms, since in some respects it may be 
closely simulated by acute gastro-enteritis; but the symptoms of the 
latter are milder. Asiatic cholera is the only disease which presents 
symptoms identical with those of cholera infantum; but, fortunately, 
in this country it is rarely necessary to suspect the comma bacillus to 
be a causative factor. Typhoid fever and appendicitis may give rise 
to symptoms simulating cholera infantum, but marked and localized 
tenderness and rigidity over the appendix in the one case, and concomi- 
tant signs of typhoid fever in the other, will exclude cholera infantum. 

Prognosis. — The prognosis is invariably unfavorable, and little hope 
of recovery can be entertained, even though the case be seen at 
the very onset; for a favorable termination seems to depend as much 
upon the previous state of health of the infant as upon promptitude 
or skill in treatment. 

Treatment. — The prophylaxis of summer diarrhea is carried out 
by means of the same precautions as are recommended to prevent 
acute gastro-enteritis. It consists in the proper care of milk during 
hot weather, hygienic living conditions in summer, and the prompt 
and efficient treatment of every case of gastro-intestinal derangement, 
however mild. 

When cholera infantum is suspected the first indication is to empty 
the stomach and bowels by means of gastric lavage and colonic irri- 
gation, using saline solution at a temperature of 90° to 100° F. This 
may be repeated every four to six hours unless collapse is threatened. 
If prostration is extreme, stimulants should be given in the form of 
hypodermic injections of atropine sulphate, -g-J-Q- to ^-q of a grain, with 
digitalin, -^iro t° tito" °f a grain, or camphorated oil, 3 to 5 minims. 
Morphine sulphate is very efficacious in controlling diarrhea and coun- 
teracting the effects of the toxins on the nervous system, but should 
be used cautiously in -£$- to ^Vgrain doses hypodermically, and should 
never be given if the infant is stuporous or comatose. 



CHRONIC GASTRITIS . 295 

Rectal or oral administration of stimulants is impossible; l>nt 
excellent results follow the supplying of normal salt solution to the 
tissues by hypodermoclysis. From 200 to 400 e.e. of warm normal 
salt solution may be injected into the loose tissues of the abdomen 
or back several times a day. If the temperature is subnormal, a hot 
mustard bath should be given, and the infant be placed in bed and 
surrounded by hot water bags. 

If the temperature is dangerously high, the baby should be put in 
a bath with the water at 100° F., and this gradually reduced to 85° 
F. An ice-bag should be kept on the head, and rectal injections of 
cold water given. If the stomach is at all retentive, 5 to 10 drops of 
champagne or brandy may be administered every hour or so, and 
cracked ice put in the mouth to allay the intense thirst. 

When improvement sets in, an attempt should be made to resume 
feeding, but nothing should be given by mouth until the symptoms 
have w T ell abated, and the first food must be predigested or peptonized. 
If this is retained, very weak broths or whey mixtures may be 
cautiously given; but milk should be withheld for at least a week. 

As soon as possible the child should be taken to the seashore, where 
the fresh sea air and change of surroundings will hasten convalescence. 

CHRONIC GASTRITIS. 

Chronic gastritis is of common occurrence in infancy and childhood. 
It is usually associated with chronic gastro-enteritis, and is secondary 
to the intestinal disturbance. Occasionally the intestinal symptoms 
are so mild that the affection may be regarded as an uncomplicated 
chronic inflammation of the stomach; but such cases are rare, and 
in the majority of them the intestines sooner or later become involved. 

Etiology. — The chief cause of chronic gastritis is prolonged and 
improper feeding, w T hich results in successive attacks of acute gas- 
tritis, and eventuates in chronic inflammation of the gastric mucosa. 
It is rare in breast-fed infants, and among its predisposing factors are 
congenital syphilis, tuberculosis, and organic disease of the heart and 
lungs; therefore if the feeding be not at fault one must suspect some 
constitutional dyscrasia. 

Artificially fed babies, whose digestive systems have been severely 
overtaxed and impaired by improper feeding in early infancy, furnish 
us with the majority of the cases of gastritis which are chronic in 
nature. Chronic gastric indigestion usually precedes this condition 
and is often due to the high percentage of fats contained in the food 
which these babies are made to take. 

Pathology. — The lesions observed in the stomach of such infants at 
postmortem simply denote a more advanced stage of inflammation 
than is seen in acute gastritis. The stomach is usually dilated, and 
inflammatory changes are diffused throughout its mucosa; in a cer- 
tain number of cases in which the organic damage is confined to the 
pylorus, the stomach may be of natural size. The mucosa is roughened ; 



296 DISEASES OF THE GASTRO-INTESTINAL TRACT 

it varies in color from a dark dusky red to faded gray; it is covered 
with a layer of thick tenacious mucus. The submucosa is usually 
thickened, while the muscular coat of the stomach is atrophied and 
weakened. 

Atrophy of the mucosa is sometimes observed in very early infancy 
as the result of chronic interstitial changes produced by long-con- 
tinued irritation from fermenting residue continually present in the, 
stomach. When sectioned and observed under the microscope, the 
mucosa shows a degeneration of the epithelium of the tubules, which 
are either enlarged or obliterated, also enlargement of the glandular 
structures as a result of chronic adenitis. 

Symptoms.— The symptoms of chronic gastritis are both local and 
constitutional. Vomiting is often persistent, and regularly follows 
each feeding period. The vomitus is composed of partly digested 
food and foul-smelling curds which may be bile-stained; in some 
instances an acid mucus is vomited by these children in the morning. 
The tongue is coated, the breath foul. In addition to vomiting there 
are eructations of gas, and frequently the passage of considerable flatus. 

In infants diarrhea is usually present, but older children with 
chronic gastritis are, as a rule, constipated. The stomach is dilated 
and tympanitic on percussion; in protracted cases, gastroptosis may 
be so pronounced that the lower border of the stomach extends far 
below the umbilicus. The abdomen is tender on pressure. There 
may be severe pain after eating, and colic of moderate degree is not 
uncommon in infants, although older children with chronic gastritis 
rarely complain of pain. 

The appetite is either very poor or capricious, and the child looks 
anemic and flabby, is always listless and fatigued, and very apt to be 
fretful and peevish during the day and restless at night. There is 
progressive loss of weight; and, because of lack of nutrition and the 
impoverished condition of the blood and tissues, eczematous lesions 
of the skin appear. These children also frequently develop a per- 
sistent pharyngeal cough which, if severe, leads to the diagnosis of 
tuberculosis. 

Infants with chronic gastritis quickly become emaciated. As the 
disease progresses all the symptoms are aggravated. There is constant 
diarrhea; vomiting persists. The appetite is ravenous but, owing 
to the failure of the digestive system to assimilate food, loss in weight 
continues. The temperature is frequently subnormal; the extremities 
are often cold and blue because of the poor circulation. Parasitic 
stomatitis or " thrush" is a usual accompaniment at this stage of the 
disease, and the infant sinks rapidly from exhaustion and malnutrition, 
being wasted to a mere skeleton. 

In older children chronic gastritis, while not quickly responsive to 
treatment, does not present the serious aspect observed during infancy. 
After infancy it is of less frequent occurrence, and the symptoms 
differ slightly. Vomiting after meals is characteristic of chronic gas- 
tritis in the child, but constipation is more apt to be present than 



CHRONIC GASTRITIS 297 

diarrhea. 'Flic appetite is perverted, and in many instances the 
articles of food craved are most harmful. The abdomen is distended 
because of gaseous accumulations in the stomach and bowels. In 
some instances there may be fever at night. 

Nearly all these children show a chronic inflammation of the mucous 
membrane of the nose or throat, although the intestines frequently 
escape. The older child does not present the pitiful spectacle that 
the infant with chronic gastritis furnishes, but is pale, anemic, fails 
to gain in weight, and easily falls a prey to acute infections. 

Diagnosis. — In these cases the cough, if persistent, and the 
emaciation often suggest pulmonary tuberculosis; but a careful chest 
examination, a microscopic study of the sputum for the tubercle 
bacillus, and a von Pirquet test will be of valuable service in differ- 
entiating the two conditions. 

Chronic gastritis must also be differentiated from tuberculosis of 
the peritoneum, which it resembles because of the persistent diarrhea 
and distended abdomen. The absence of fluid in the peritoneal cavity, 
which can be demonstrated by physical examination, and a skin test 
for tuberculosis in addition, will usually exclude the tuberculous 
condition, since this differentiation is not at all difficult. 

The history of the case is of extreme importance in establishing the 
diagnosis of chronic gastritis; while a test meal will often aid us in 
demonstrating the absence of those digestive changes which are pro- 
duced by an insufficiency of hydrochloric acid and pepsin, together 
with an excessive formation of lactic and butyric acid, and a contin- 
uous outpouring of mucus. 

Occasionally a case of chronic gastritis may suggest, in the earlier 
stages, typhoid fever, but there is really little similarity, and a Widal 
test will usually rule out this infection. If congenital syphilis is thought 
to be the primary cause, a therapeutic test should be made, since it 
rarely does harm and is often followed by improvement. 

Prognosis. — In chronic gastritis the prognosis depends largely upon 
the age and the physical condition of the patient when treatment is 
begun. Young infants, in whom atrophic changes in the gastric 
mucosa have already taken place, have but slight chance for a favor- 
able outcome. In children one or two years old, the chances for 
recovery are somewhat more favorable than in early infancy, as the 
debility of the infant renders it extremely susceptible to secondary 
infection. In older children there is practically no actual mortality 
from chronic gastritis; but it is most difficult to treat, and runs a very 
protracted course. 

Treatment. — The treatment of chronic gastritis depends for its 
results upon the fidelity with which the dietary and hygienic instruc- 
tions and regulations are followed by those in charge of the child. 
The diet should receive the utmost consideration. It is advisable at 
first to restrict the strength and amount of food to the minimum, and 
gradually to increase it as improvement is noted. 

When treatment is first instituted milk should be withheld from 



298 DISEASES OF THE GASTRO-INTESTINAL TRACT 

the infant for a short time, and barley water, albumin water, or weak 
broths substituted. If breast-fed, the infant may be allowed to 
resume nursing in forty-eight hours; but full quantities should not 
be permitted until there is marked improvement in the stomach 
symptoms. Artificially fed babies should be deprived of milk for an 
even longer time than the breast-fed; and, when milk is once more 
allowed, it should be given in small quantities at first, and gradually 
increased as digestion improves. 

In some cases digestion is so very poor that it may be necessary 
to give predigested foods, or to add a peptonizing powder to the milk 
at each feeding, and if nothing given by mouth is satisfactorily 
digested, rectal feeding must be resorted to in order to keep up the 
child's nutrition, and the stomach may be given a complete rest. 
Older children rarely require so great restriction of diet, but should not 
be allowed the articles of food they prefer if they are at all indigestible. 

In the treatment of gastritis a liquid diet should be maintained 
until the stomach shows marked improvement. Broths and clear 
soups with dry toast should first be given; and, if this food is well 
borne, scraped beef or tender chops may be permitted, adding a little 
to the daily menu until the full amount of nourishment is taken, and 
thus improve the poor physical condition of the patient. The period 
between nursings should be lengthened an hour in infants, and older 
children forbidden to eat between meals. If vomiting continues 
after restriction of the diet, the stomach should be w T ashed out daily 
before the midday meal to bring away the coating of mucus which 
collects on the gastric mucosa, and seriously inhibits digestion. In 
these cases warm sterile water or salt solution may be used for washing 
the stomach; but a solution of sodium bicarbonate, 5j to the pint 
of water, is preferable if fermentation is present. 

Drugs alone will have no appreciable effect upon chronic gastritis; 
but because of the frequent deficiency of hydrochloric acid in the 
gastric secretion of infants this acid is often given in 1- or 2-drop doses, 
and may to advantage be combined with tincture of nux vomica in 
1-drop doses. Older children are given correspondingly larger doses 
of these two drugs. In addition a daily dose before breakfast of sodium 
phosphate is necessary to regulate the bowels. Cerium oxalate, 
2 grains, and menthol, 1 grain, given every three hours, are often 
valuable in controlling persistent vomiting. 

After the diet, the most important considerations in the treatment 
of a child with chronic gastritis are the environment and living con- 
ditions, and proper hygienic surroundings will aid materially in 
hastening the recovery of these little ones. An infant should be kept 
out of doors all day on a bed taken to the roof, or it may be put on 
the porch in its coach. Older children should be encouraged to play 
out of doors, but not to the point of fatigue. If possible, they should 
be sent to the country or seashore after steady improvement has set 
in, since relapses are quite common, and can be prevented only by 
ideal management of the case and hygienic environment. 



DILATATION OF THE STOMACH 299 



DILATATION OF THE STOMACH. 

Chronic dilatation of the stomach is quite common in infancy and 
childhood, and is most frequently the result of chronic gastric indiges- 
tion or chronic gastro-enteritis. Acute dilatation of the stomach, 
while less common than the chronic form, is observed oftener in 
children and infants than in adults. 

Etiology. — In infants and young children the stomach becomes 
dilated from quite trivial causes, but the condition is often merely 
temporary. Only when there are continuous or oft-repeated signs of 
gastric derangement does permanent dilatation take place. Children 
with a constitutional dyscrasia, such as tuberculosis, syphilis, rachitis, 
or marasmus, frequently suffer from dilatation of the stomach due 
to the atonic condition of the stomach wall, which impairs gastric 
motility, and results in the retention of a residue and consequent 
fermentation. 

A less common cause of gastric dilatation is an obstruction within 
the gastro-intestinal tract, such as pyloric stenosis or partial obstruc- 
tion of the bowel. In a great many cases gastric dilatation is the 
result of recurring or continuous distention of the stomach due to 
fermentative gastric indigestion. A severe and acute form of dilata- 
tion of the stomach sometimes occurs in scarlet fever, in typhoid 
fever, in pneumonia, and in chloroform poisoning. 

Pathology. — At postmortem the stomach is generally found to be 
much larger than has been suspected from clinical evidence during 
life. Cases have been reported in which the gastric capacity was 
three times that of a normal infant. Chronic catarrhal gastritis is 
usually present, and the thinness of the stomach wall is evidence of 
considerable atrophy of its muscular coat. 

Symptoms. — The symptoms presented by a child with chronic 
dilatation of the stomach are principally those of the associated chronic 
gastritis. Vomiting is persistent, and may occur periodically at 
intervals of twelve to twenty-four hours. Mucus may be vomited in 
the morning when the stomach is empty; but, as a rule, vomiting 
follows the nursing or feeding period, and the vomitus contains undi- 
gested food or milk curds from several preceding feedings, showing 
that although food is retained hi the stomach much longer than 
normally, digestion is so faulty that the stomach contents are prac- 
tically unaltered by the action of the gastric juice. 

The tongue is coated, the breath is fetid. The child either has 
chronic diarrhea or is markedly constipated. Eructations of gas occur 
at frequent intervals, and there is usually considerable flatus. The 
stomach is ballooned, and tympantic on percussion; the lower border 
may extend well below the umbilicus. The abdomen is tender, espe- 
cially around the epigastrium. There may be considerable pain after 
eating. 

As a rule the appetite is poor, and the child quickly loses weight, 
becomes anemic and flabby looking, and is exhausted from lack of 



300 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

nourishment. It is apt to be peevish during the day and restless at 
night. Occasionally convulsions are noted. Extreme thirst is one of 
the few characteristic symptoms of chronic dilatation of the stomach, 
and is very difficult to assuage. Chronic gastric dilatation gives rise 
to indefinite and vague symptoms; acute dilatation of the stomach 
may manifest itself suddenly, and its symptoms are of greater severity. 
Dyspnea may appear from pressure of the distended stomach upon 
the heart. 

The infant or child soon loses color, and appears to be very ill. 
Upon percussion the epigastrium is found to be tympanitic from the 
ensiform cartilage down to well below the umbilicus; but it is diffi- 
cult to differentiate the gastric tympany from that caused by colonic 
distention. x\cute dilatation of the stomach to a moderate degree 
often occurs during infancy; but is relieved by the eructation of gas, 
and does no harm unless repeated too frequently. 

Diagnosis. — When there is a history of long-standing chronic gas- 
tritis, and a large area of tympany is found over the epigastrium, the 
diagnosis of chronic dilatation of the stomach is not difficult; But, 
unless some practical method of gauging the stomach contents is 
used, there will be extremely wide variations between the clinical 
estimation of the degree of dilatation and the postmortem findings. 

In the case of an infant or young child it is sometimes possible to 
calculate the capacity of the stomach by filling it with water, and 
noting the amount required. Transillumination may be a valuable 
aid in outlining the boundaries of the organ, and in differentiating 
gastric dilatation from colonic distention, which is the only condition 
that can possibly be confounded with dilatation of the stomach. 

Prognosis. — Chronic dilatation of the stomach does not necessarily 
endanger the life of the child, but is often the cause of a prolonged 
chronic gastritis inasmuch as, when present as a complication of a 
chronic stomach affection, it renders treatment very difficult. 

This superadded condition may be the indirect cause of death during 
infancy by reducing the digestive power of the stomach to a dangerous 
degree. When acute dilatation of the stomach exists alone, recovery 
is much more rapid; but in those cases where the dilatation is due to 
organic lesions, such as stenosis of the pylorus, or congenital stenosis 
of the duodenum and ileum, the outlook is very unfavorable. 

Treatment. — The restriction and regulation of the diet is the most 
important measure for the relief of chronic dilatation of the stomach. 
The breast-fed infant should be deprived of milk for a day or so, 
and barley-water, albumen-water, and weak broths be substituted. 
At the end of this period the child may again be put to the breast, 
but only for a few minutes at each nursing period. 

At first it is well to increase the length of time between the feedings ; 
but when improvement sets in the nursing periods may be gradually 
increased and the intervals between them shortened, until the child 
is again taking its full quota of nourishment daily. Artificially fed 
infants mav be taken off milk for a week or ten days if necessary; 



PYLOROSPASM 301 

if the digestion be very poor, the food may be either predigested or 
given by reetum. 

In older children chronic dilatation of the stomach is never as serious 
as in infancy, and frequently careful regulation of the diet and absten- 
tion from pastry, candies, fried and other indigestible foods, are suffi- 
cient to bring about amelioration. The ingestion of large quantities 
of liquids should be avoided. The stomach should be washed out 
daily as long as vomiting continues, using warm saline solution or 
an aqueous solution of bicarbonate of soda, 3j to a pint of 
water. 

The tincture of nux vomica is often of great value in the treatment 
of chronic dilatation of the stomach because of the atonic condition 
of the stomach wall. It may be given in 1-drop doses, three times 
a day, to a child of one year, or in 5-drop doses, three times a day, 
to a five-year-old child, and is best administered at meal times in 
combination with an organic preparation of iron. 

Children with chronic dilatation of the stomach often show marked 
improvement if sent to the seashore or country; but when this is 
impossible much can be accomplished at home by insisting on outdoor 
life, and fresh air and sunshine. 

Acute dilatation of the stomach is often relieved spontaneously 
by the eructation of gas, which can sometimes be made more effectual 
by the administration of a few drops of spirits of chloroform, Hoff- 
man's anodyne, or peppermint-water. If stimulation is required, 
camphorated oil in drop doses may be given to an infant hypoder- 
mically, or 1 dram of brandy and a half-ounce of black coffee by rectal 
injection. If the diet is regulated after the first attack of acute dilata- 
tion of the stomach, it will go far toward preventing further trouble. 

PYLOROSPASM. 

Spasm of the pylorus, while by no means a common affection in 
infancy, occurs with much greater frequency than does hypertrophic 
pyloric stenosis, although few cases are recognized. In the majority 
of instances it is thought to be hypertrophy of the pylorus until the 
results of operation or the effects of medical treatment exclude the 
possibility of its being an organic lesion. 

Etiology. — Pylorospasm is usually seen in bottle-fed babies, rarely 
in the breast-fed. It is often brought on by a sudden change from 
mother's to cow's milk, and is usually accompanied by either hyper- 
secretion of gastric juice or hyperacidity. The frequency of gastric 
disturbances in infancy and the rarity of pylorospasm make it evident 
that other contributing factors must be active in causing this condition; 
but the exact nature of these influences is as yet most obscure. 

It has been noted that the majority of infants with pylorospasm 
are nervous and excitable, manifesting a hereditary neurotic tendency 
which results in hyperirritability of the pyloric sphincter in common 
with all other muscles of the body. The normal extreme irritability 



302 DISEASES OF THE GASTROINTESTINAL TRACT 

of muscle tissue in early infancy probably explains to a certain degree 
the occurrence of the disease at this period. 

Pathology.— On postmortem examination the stomach and esopha- 
gus are usually greatly dilated, the mucous membrane is congested 
and formed into folds much like those observed in hypertrophic 
stenosis of the pylorus; but in uncomplicated cases of spasm there 
is neither tumor formation nor increase of tissue at the pyloric end 
of the stomach, and the degree of stenosis is not so extreme. 

Symptoms. — Vomiting is the chief, and sometimes the only marked 
symptom of pylorospasm; especially is this true in mild cases where 
the infant is apparently healthy in every other respect. Weeks and 
even months may elapse after birth before the infant begins to vomit; 
but from the time vomiting sets in it is persistent. 

The baby usually vomits soon after food reaches the stomach; 
either the stomach contents are all ejected at once or small quantities 
are brought up at frequent intervals. Rarely does the amount of 
vomitus exceed the quantity of food taken at the last feeding. On 
examination of the vomited material there is no evidence of fermen- 
tation or other gastric disturbance. The stools may be nearly nor- 
mal in size, notwithstanding the constipation, and the child may 
be fairly well nourished because of the amount of food retained by 
the stomach and passed into the intestine. 

In serious cases of pylorospasm the symptoms closely simulate 
hypertrophic pyloric stenosis. Vomiting is severe, and may be explo- 
sive in character. Practically everything eaten is rejected by the 
stomach, so that the infant rapidly loses weight. Obstinate constipa- 
tion with very small stools is caused by the deficiency of digestive 
residue in the intestines. 

Antiperistaltic waves can be observed on inspection of the abdomen 
immediately after food is taken; but these disappear after the stomach 
contents are ejected or passed into the duodenum. Occasionally a 
tumor is palpable at the pylorus, but it is much smaller than the 
mass felt in cases of hypertrophic pyloric stenosis, and if it is palpated 
carefully a change in size will be noted corresponding to the contrac- 
tion and relaxation of the pyloric sphincter (Fig. 29) . 

In mild cases no peristaltic wave may be visible and no tumor 
felt, but if arrays are taken after a bismuth meal, marked inter- 
ference with the passage of the stomach contents into the duodenum 
will always be observed (Plate III). 

Diagnosis. — As a rule the diagnosis of obstruction at the pyloric 
end of the stomach is not difficult, but a severe case of pylorospasm 
may so simulate a mild case of hypertrophic pyloric stenosis, or a mild 
case of hypertrophic pyloric stenosis may so much resemble a severe 
case of pylorospasm, that the differentiation is sometimes impossible. 

The chief symptoms which favor pylorospasm, however, are the 
slight impairment of nutrition, the moderate constipation, the fairly 
normal gastric digestion, and the absence of a palpable tumor of 
fixed size at the pylorus. Although the symptoms of pylorospasm 



PLATE III 




Boy, Aged Four and One-half Years; Weight, Thirty-three 
and One-half Pounds, Frequent Attacks of Vomiting. Palpable 
Tumor at Pylorus. 

There is constant irregularity in the outline of the pylorus, and upon 
palpation under fluoroscopic observation there is partial fixation as well as 
palpable thickening. At six hours there is almost complete retention of 
the barium meal in the stomach. In the erect posture the stomach does not 
empty. When the patient lies on the right side, the barium meal leaves the 
stomach in a very small stream. Stomach dilated. 



PYLOROSPASM 606 

are much milder than those of hypertrophic pyloric stenosis, there 
is a marked contrast between vomiting due to spasm of the pylorus 
and habitual vomiting. In the latter condition the child dots not 
suffer from loss of nourishment, the stools are normal in size and 
number, and the vomiting, never projectile, can be attributed to a 
certain extent to conditions outside the stomach. 

Prognosis. — In the majority of cases the prognosis Is good if treat- 
ment is carried out faithfully, and the amount of intestinal residue, 
as shown by the size of the stools, is a fair indication of the progress 
of the disease. The course of a case of pylorospasm is usually pro- 
tracted, but recovery under medical treatment should be anticipated 
except in the gravest cases where surgical intervention is sometimes 
necessarv to save life. 




Fig. 29. — Pylorospasm in an infant two months old, showing peristaltic waves. 



Treatment. — Dietetic regulation is the most important phase in 
the treatment of pylorospasm, and it is a question whether appreciable 
results can be obtained from any other therapeutic measures. The 
breast-fed infant should be allowed to nurse for only a few minutes 
at a time, and the intervals between nursing should be an hour longer 
than is normally required for the stomach to empty itself. If the 
mother's milk contains a high percentage of fat, the quantity allowed 
at each feeding should be reduced still further, and this deficiency in 
the amount of the feeding made up by giving the infant from a dram 
to a half-ounce of lime-water after each nursing. 

Since, however, it is most frequently the artificially fed infant who 
suffers from pylorospasm, proper modification of cow's milk in these 



304 DISEASES OF THE GASTRO-INTESTINAL TRACT 

cases is, perhaps, the most important consideration in the regulation 
of the diet. The strength of the formula given will depend, of course, 
upon the age and weight of the infant with pylorospasm, just as in 
any other feeding case; but, bearing in mind the fact that it is most 
desirable to have as much of the stomach contents pass the pylorus 
as possible, an attempt should be made to give a mixture which 
will pass readily into the duodenum, because of the relatively rapid 
digestion of its constituents and the lack of curd formation. 

From this point of view it will be readily seen that the carbohydrate 
content may be unchanged, inasmuch as lactose leaves the stomach 
early, and does not give rise to curd formation; that protein is better 
given in the form of whey to prevent so far as possible the formation 
of large casein curds; and that the fat content of such a formula 
should be greatly reduced because of the length of time required for 
the stomach to empty itself after a feeding rich in fats. Olive oil, 
five drops three times a day, is often retained and well digested, and 
frequently the dose may gradually be increased to 10 or 15 drops 
three times a day. I have often seen fat in this form retained and 
well digested when cream, even in the smallest amounts, could not 
be tolerated. 

The addition of lime-water to such a formula should be much in 
excess of that used for the ordinary feeding case, on account of the 
hyperacidity of the gastric juice in these cases. It is the safest plan, 
however, to allow the degree of alkalinity of the mixture to depend 
upon the amount of hyperacidity as determined by gastric analysis, 
since hyperalkalinity might prove to be as active an exciting factor 
in provoking pylorospasm as hyperacidity. Besides, in addition to 
the beneficial effects of neutralizing the hyperacidity of the gastric 
juice, the addition of an alkali to the formula delays the coagulation 
of casein by rennin, and thus helps to eliminate the protein curds in 
the gastric contents, and favors their easy passage into the duodenum. 

It is, perhaps, the best plan to reduce considerably the amount 
given at each feeding. To a certain extent this quantity will depend 
upon the size and age of the child, but the severity of the symptoms 
should also serve as a guide. In aggravated cases it may be advisable 
to give but a dram or two of the mixture at each feeding, increasing 
this amount gradually as improvement is noted. 

If too little food is retained to nourish the infant or sustain life, a 
No. 15 catheter may be passed through the pylorus, and food be thus 
introduced into the duodenum. The stomach should be washed out 
daily with a 5 per cent, solution of sodium bicarbonate. Rectal 
injection of normal saline or Ringer's solution is also advocated because 
of the theory that instillation of salt solution in the rectum diminishes 
the secretion of the gastric juice. 

In these cases there are no drugs which have any appreciable effect 
upon the frequency or severity of the vomiting; but paregoric is 
sometimes given in 5- to 10-drop doses, and cocaine also by mouth 
in weak solution for its anesthetizing effect upon the mucous mem- 



HYPERTROPHIC PYLORIC STENOSIS 305 

brane of the stomach. Bromide of soda in 2-grain doses, three times 
a day, tends in sojne cases to lessen the tendency to spasm at the 
pylorus. In addition, warm spice poultices are sometimes applied 
to the epigastrium immediately before and after feeding. 

The majority of cases of pylorospasm will show slow but progressive 
improvement under medical treatment, and eventually recover; but 
in a few instances, despite careful regulation of the diet and the best 
attention, an infant will fail to improve, and steadily grow worse, and 
then surgical intervention is warranted. If the physical condition be 
good, posterior gastroenterostomy is not attended by high mortality, 
and it offers the only possible chance for life. 

HYPERTROPHIC PYLORIC STENOSIS. 

Hypertrophic pyloric stenosis is a condition which usually occurs 
in early infancy, and is the result of congenital hypertrophy of the 
sphincter muscle at the pyloric end of the stomach. The excess of 
muscular tissue at the pylorus forms a tumor there which so narrows 
the inner diameter of the pyloric orifice that, instead of measuring 3 
to 3J mm., as in the normal infant, it will barely admit a small probe. 

Etiology. — Hypertrophic pyloric stenosis is essentially a disease of 
infancy, and in more than 50 per cent, of the cases the symptoms 
appear before the second week. After the eighth week the disease 
is comparatively rare. However, a number of such cases have been 
reported in older children. 

I have recently seen, in consultation with Dr. Betts, a boy, four 
years of age, with a palpable tumor at the pylorus. This boy was 
nursed until he was a year old, and developed normally. From the 
age of one to two years he gained slowly in weight. Since he was two 
and a half years old, he has had, every four to six weeks, attacks of 
severe vomiting with a slight fever. These attacks last ordinarily 
for forty-eight hours. During the past year and a half he has not 
seemed as well or as strong as he ought to be, and he is always pale 
and constipated. On December 2, 1915, in one of these brief illnesses, 
he vomited some spinach that he had eaten fourteen hours previously. 
The .r-ray plates show that at six hours there was almost complete 
retention of the barium meal in the stomach. In the erect posture 
the stomach did not empty at all; but when the patient lay on the 
right side we got a fairly good view of the barium meal leaving the 
stomach in a very small stream. iVt twenty-four hours all the barium 
meal was found in the colon, the stomach being entirely empty of it. 

Many of the cases occur in the first-born child, and boys are more 
subject to the disease than girls. Observers are not united in the 
opinion that the hypertrophy of the sphincter muscle is congenital; 
some insist that it is the result of too frequent muscular spasms during 
the first few days of life, caused by gastric or duodenal irritation. 
But while it is true that hyperacidity is usually associated with 
pyloric stenosis, no conclusive evidence has been brought to light 
20 



306 DISEASES OF THE GASTRO-INTESTINAL TRACT 

that would lead us to believe that the condition can be attributed 
to improper feeding or hyperacidity. The actual cause of this disease 
is therefore still a mooted question. 

Pathology. — On examination of the stomach the pylorus is readily 
detected as a hard tumor mass the lumen of which is so small that a 
thin probe can be passed through only with difficulty. The stomach 
is usually dilated, the muscular coat hypertrophied throughout. The 
mucous membrane lining the stomach is thickened, roughened, cov- 
ered with mucus, and also shows signs of gastritis. In some cases 
the longitudinal folds of mucous membrane extend into the pylorus, 
and completely occlude that orifice. The intestines are contracted, 
atrophic, and, for the most part, empty. When examined under 
the microscope, a longitudinal section of the pylorus reveals intensely 
hypertrophied muscle fibers, and also hypertrophy of the mucous 
membrane in this region; but the longitudinal muscle fibers are but 
little, if at all, affected. 

Symptoms. — At birth the infant with hypertrophic pyloric stenosis 
is apparently normal, and usually remains in good health for several 
days or a week ; but, sooner or later, the chief symptom of this disease 
appears, and the child vomits persistently after each feeding without 
regard to what is fed. Sometimes two or three feedings are retained, 
and then expelled simultaneously. As the disease progresses the 
vomiting becomes forcible and projectile in character; it tends to 
persist, and grows worse despite regulation of the diet and all other 
measures instituted to control it. When several nursings are retained 
before being vomited the stomach may become greatly dilated, and 
gastric peristalsis is visible. A palpable tumor can usually be detected 
in the pyloric region, and easily identified as the hypertrophied pylorus. 
Although the epigastrium may be quite prominent, the lower abdomen 
is concave and sunken owing to the fact that the intestines contain 
very little fecal matter or food residue, since it is impossible for much 
food to pass into the duodenum. The infant is constipated because 
of the lack of intestinal contents, and in those cases where hypertrophy 
of the pylorus is accompanied by pylorospasm, very little fecal matter 
is passed from the time the disease becomes manifest until death. 
The stools sometimes resemble meconium, and contain bile and a 
small amount of food residue. The loss in weight is rapid and exces- 
sive, and unless relieved the child eventually starves to death. In 
a few weeks the infant is reduced to a mere skeleton with sunken eyes, 
flaccid abdomen, and dry skin and lips. The large dilated stomach 
makes the epigastrium the most prominent part of the body, and as 
the infant lies on its back in a state of exhaustion peristaltic waves, 
perhaps several at a time, become visible and can be seen to run 
slowly across the upper abdomen from left to right. The temperature 
is normal or subnormal. The appetite is usually ravenous, but there 
is no other symptom of gastric disturbance. 

Diagnosis. — The diagnosis of a typical case of pyloric stenosis is 
not difficult, and can sometimes be made with reasonable certainty 



HYPERTROPHIC PYLORIC STENOSIS 30i 

from a history of the vomiting. If an otherwise healthy breast-fed 
infant vomits persistently, having begun to do so a few days after 
birth, and if the vomiting has become more forcible and projectile 
in character, and continues in spite of all regulation of diet and other 
measures to stop it, and if no other symptoms of gastric derangement 
are present, we should certainly be inclined to consider the case pyloric 
stenosis. A careful physical examination of the abdomen should be 
made shortly after feeding, and, after the epigastrium has been closely 
scrutinized for the peristaltic wave, an endeavor made to palpate the 
tumor at the pylorus. If the peristaltic wave be seen and the tumor 
found, the diagnosis is amply confirmed. 

Indigestion accompanied by vomiting is easily excluded if other 
symptoms of indigestion are absent and by the facts that the infant 
is being breast fed and there is no cause for any derangement of diges- 
tion. Emaciation is much more rapid in hypertrophic pyloric stenosis, 
and there is neither foul breath, coated tongue, anorexia, nor diarrhea 
such as is found in gastric indigestion. Simple pylorospasm presents 
most of the symptoms of hypertrophic pyloric stenosis, and in some 
instances it is impossible to differentiate these two conditions posi- 
tively. 

In a typical case of hypertrophic stenosis, however, a differentiation 
can be made with reasonable certainty. Constipation is much more 
marked in stenosis than in spasm; the baby is usually breast fed in 
a case of stenosis and artificially fed in pylorospasm; moreover, if 
the tumor on palpation does not vary in size and shape, the evidence 
is almost conclusively in favor of hypertrophic stenosis. Dilatation 
of the stomach is strongly suggestive of hypertrophic stenosis, and 
failure to improve under proper treatment is reasonable evidence of 
an organic lesion. Habitual vomiting of infancy may be mistaken for 
hypertrophic pyloric stenosis; but in habitual vomiting of infancy 
there is no constipation or loss of weight, and the baby continues to 
thrive, whereas in hypertrophic pyloric stenosis it fails rapidly. 

Prognosis. — The prognosis in hypertrophic pyloric stenosis depends 
upon the extent of the hypertrophy and the physical condition of 
the child when brought under observation. If there is a considerable 
degree of hypertrophy, medical treatment affords no hope of recovery ; 
and if it seems likely that the child will survive the shock of an opera- 
tion pyloroplasty or posterior gastroenterostomy should be performed, 
and will be followed by recovery in a large majority of cases, if done 
by a skilful surgeon. If but a slight, degree of hypertrophy is present, 
there may be great improvement after proper medical treatment. 

Treatment.— From many points of view, surgical treatment of 
hypertrophic pyloric stenosis is far preferable to medical attention. 
Extensive hypertrophy at the pylorus demands immediate operation 
as the only chance for recovery. With a moderate degree, the patient 
improves but little under medical treatment, and it is doubtful whether 
even a very slight hypertrophy of the pylorus is benefited at all. 

Unless the obstruction, however insignificant, be removed, there 



308 DISEASES OF THE GASTRO-INTESTINAL TRACT 

remains a potential factor for benign obstruction of the pylorus in 
later years. In some cases the pylorus may be dilated by means of 
forceps introduced into the stomach; but the best results follow pyloro- 
plasty and posterior gastroenterostomy. Before operation the stom- 
ach should be washed out and salt solution given by rectum for 
absorption. Enteroclysis may be continued after operation, or the 
saline may be given subcutaneously in an emergency. 

As soon as postanesthetic nausea has subsided the child may be 
put to the breast; but only a dram or two of milk should be allowed 
at a time, and this should be followed by a half ounce of water after 
each nursing. The breast is allowed every hour, however, until the 
amount at each feeding can be increased, after which normal feeding 
is gradually resumed. 

If operation is contra-indicated, the feedings are reduced and 
gradually again increased, just as in the postoperative cases, and the 
stomach is washed out daily. If spasm of the pylorus is complicating 
a mild degree of hypertrophy, it is sometimes possible to feed these 
infants by catheter. Bicarbonate of soda in 2- to 5-grain doses, 
three times a day, acts very well. If a sedative is required, 5 drops 
of paregoric may be given. When all means of introducing food into 
the stomach fail, an effort must be made to keep up the nutrition of 
the infant by means of nutrient enemata. 

PYLORIC STENOSIS IN OLDER CHILDREN. 

It is not my intention to study here the condition spoken of as 
congenital pyloric stenosis in infants, but to consider stenosis of the 
pylorus in children who have passed the period of infancy. The study 
of the condition in older children must, however, embrace those 
patients in whom the condition has persisted from infancy into later 
childhood, as well as those cases in which infancy has been free from 
all symptoms of pyloric stenosis, but in which the symptoms appeared 
months or years later. 

At the outset of this study one is immediately impressed by the 
fact that while medical literature is crowded with articles on con- 
genital hypertrophic pyloric stenosis and pyloric spasm in infants, 
there has been, as far as I am aware, little written exclusively on the 
condition in older children. 

The discussion in all of these papers deals with the problem as to 
whether the condition is congenital or not; as to the cause of the 
hypertrophy of the circular muscular fibers at the pylorus; as to 
whether in a given case the condition is one of pyloric spasm simply, 
or hypertrophic stenosis simply, or both spasm and hypertrophy, and 
as to the necessity for an operation. 

The etiology of these congenital or early cases of pyloric stenosis 
has been considered as due, perhaps, to gastric hyperacidity, or at 
least to some disturbance of gastric secretion and consequent gastric 
indigestion. Other causes are hyperplasia at the pylorus, edema of 






PYLORIC STENOSIS IN OLDER CHILD REX 309 

the mucous membrane of the pylorus and pyloric spasm. The causes 

of spasm are not clear. It may he due to a toxemia, to gastric dilata- 
tion, to a change in the gastric secretion, or it may be nervous in 
origin. The classical symptoms are vomiting, constipation, progres- 
sive loss in weight, scanty urine, visible peristaltic waves, and possibly 
the finding of a tumor at the pylorus. 

The treatment ordinarily advised is feeding, stomach-washing, 
opium, poultices to the epigastrium, saline enemata for the purpose 
of absorption of liquid, nutrient enemata, operation. 

A study of the subject of organic pyloric stenosis as found in Ameri- 
can, English, German and French literature has impressed forcibly 
on me the belief that a careful clinical examination of children and 
young adults will result in bringing to light a fair proportion of cases 
of organic stenosis during this period of life. The condition was long 
overlooked in infants; and while not flattering to clinicians, it is, 1 
believe, nevertheless true that the condition is now being overlooked 
in the older child and young adult. 

Children and young adults 1 who present gastric symptoms that 
continue for months or years, and especially if vomiting and epigastric 
pain are present, may be suffering from organic pyloric stenosis, and 
if such patients have been treated for a long time medicinally without 
benefit, the probability of there being organic pyloric stenosis increases. 
Many such cases have finally come to operation, and a pyloric stenosis 
found by the surgeon at operation. 

The reason why medical treatment failed in these patients is then 
clear. Permanent changes have taken place in the gastric secretory 
apparatus as the result of the long continuance of the hypertrophic 
stenosis, and a cure by medical treatment is impossible. An early 
recognition of the pyloric obstruction should in a fair, or probably in 
a large, proportion of these cases lead to their cure by medical rather 
than surgical treatment. This seems at least probable, if one is to 
reason by the results obtained in pyloric stenosis in infants and older 
children. A study of the cases in infants and older children treated 
medically shows conclusively that the majority of those infants who 
suffer from a mild degree of hypertrophic pyloric stenosis are cured 
by the physician and do not come to operation. Heubner 2 reports 
19 cured in 21 infants; Bendix, 3 30 in 32 cases; Hutchinson, 4 13 in 
14 cases. Stark, 5 11 out of 12 cases; Bloch, 6 6 patients, all recovered. 

I do not wish to be understood as implying that there are not 
patients who require operation. I believe that the position taken 
on the question of operation by Robert Hutchinson, 7 "that operation 
is never in any circumstances justified in these cases," is an extreme 
one, but that most of the cases of slight and moderate pyloric stenosis 
can be cured by medical treatment is my firm belief. 

1 Maylard, British Med. Jour., July 11, 1908, p. 71. 

2 Therap. d. Gegenw., 1906, vol. viii. s Med. Klin., 1909, vi, 1813. 

4 Clin. Jour., September 9, 1908. " B Zentralbl. f. Kinderh., 1909, xiv, 5. 

6 Jahrb. f. Kinderh., 1907, lxv, 317. 7 Loo. cit. 



310 DISEASES OF THE GASTRO-INTESTINAL TRACT 

It is jni accepted fact that many patients live into advanced adult 
life who at autopsy show congenital pyloric stenosis. Rudolph Mayer 1 
reports 31 such cases. Cautley and Dent 2 report 3 cases of pyloric 
stenosis at the age of six, eleven and twenty-two years, respectively, 
and believe they were probably congenital. Mayo Robson reports 
1 case, Lauderer 3 10 and William Russell 4 3 cases. 

There is probably no doubt that congenital pyloric stenosis of a 
mild grade may remain latent for months and probably for years, and 
cases of organic pyloric stenosis have been observed during the second 
and third years of life, w T here a distinct insufficiency of motility, 
together with hyperacidity existed. There is probably hardly any 
year between early infancy and well-advanced old age that does not 
show cases of pyloric stenosis in which the patients have come to 
operation. Some of these patients have had gastric symptoms from 
childhood; in others the symptoms vary from a few months to a 
number of years. Rosenheim 5 reports a case in a child who had 
always enjoyed good health until an attack of measles at the age of 
five years, from which he made a good recovery. Three months later 
the child began to vomit and continued to vomit almost every day. 
When six and a half years of age he w r as operated on and found to be 
suffering from hypertrophic pyloric stenosis. The case ended in 
recovery. Osier reports a case of hypertrophic pyloric stenosis in 
a child that lived until the third year. 

There is much room for thought in the study of the cases in which 
the hypertrophic stenosis is not sufficient in amount to produce 
dangerous symptoms in infancy. The hypertrophy gradually increases 
in degree, the stenosis becomes more marked, and in later years the 
child presents the symptoms directly and indirectly produced by 
the stenosed pylorus. Beardsley reports a case at the age of four 
years, Sonnenberg one at five years, and Hansy one at eleven years 
(Cautley 6 ). 

Then there are cases that present exactly the opposite picture. The 
symptoms of hypertrophic pyloric stenosis are very severe in infancy; 
the babies are so ill that it seems as if they must surely die. They 
recover, however, and at the age of three or four years are apparently 
perfectly well. Robert Hutchinson has reported such cases. 

The question naturally arises, what has occurred in these cases? 
Has the congenital hypertrophy of the pylorus largely or partly disap- 
peared? Has the compensatory hypertrophy of the stomach muscles 
been sufficient to overcome the original condition, and has no gastric 
dilatation occurred, or has it been a combination of both conditions? 
Cases are reported in which apparently no gastric dilatation has 
occurred, and the evidence in such cases points strongly to absorption 
of the hypertrophy. 

1 Virchow's Arch. f. Path. Anat., 1885, cii, 413. 

2 Tr. Roy. Med. and Chir. Soc, 1902, lxxxvi. 

s Tubingen, 1879. " "British Med. Jour., July 11, 1908. 

B Berl. klin. Wchnschr., 1899, xxxii, 703. fi Diseases of Children, 1910, p. 204. 



PYLORIC STLXOSfS IX OLDER ('IIILI)RLX Sll 

What is the explanation of the very large percentage of recoveries 
reported by certain observers Heubner, Bendix, Hutchinson, Stark, 
and Bloch? I believe it is as follows: Many of these cases are instances 
of pyloric spasm; others are cases of slight hypertrophic pyloric steno- 
sis; in still others, both spasm and a mild degree of hypertrophy exist, 
and if one is ready to admit that a slight amount of hypertrophic 
pyloric stenosis may be largely or in part absorbed, the explanation 
is quite satisfactory. Stiles, who has operated on many of these 
patients, claims that true congenital hypertrophic stenosis of the 
pylorus is rare, and, when it does occur, should be treated surgically. 
Cautley is of about the same opinion, but believes that very mild 
cases of this disease may recover under medical treatment. Cases 
of this character may, and probably do, in some instances, show 
gastric symptoms and evidence of pyloric stenosis in later life, since 
persistent stenosis in the older child is represented by, first, a period 
of compensatory stomachic muscular hypertrophy; this is followed 
by a period which may exist from the inception of the stenosis which 
represents stagnation and the slow emptying of the stomachic con- 
tents; and lastly, retention, or the failure of the stomach ever to 
completely empty itself. Is it not possible to recognize these cases 
clinically? Should they come to operation undiagnosed? 

The following conclusions in regard to hypertrophic pyloric stenosis 
in older children and young adults seem to me to be justifiable: 

1. Pyloric stenosis is present in children and young adults more 
commonly than is supposed. 

2. The age at which it manifests itself depends on the degree of 
stenosis present. 

3. Pyloric stenosis may be latent for years. 

4. It is found by the surgeon during childhood and young adult 
life, and its early recognition by the physician is important from the 
standpoint of early medical or, if necessary, surgical treatment. 

5. The entire disappearance of all the classical symptoms of con- 
genital hypertrophic stenosis, and the apparent health of the infant 
during its subsequent early childhood, suggest the probability of an 
absorption of the hypertrophy, especially as no gastric dilatation 
may develop latex in life. 

The stomach through the sympathetic and cerebrospinal nerves is 
connected with practically all organs and tissues in the human body, 
and it has been demonstrated that pyloric spasm can be produced 
artificially by stimulation of the vagus. The contraction of involun- 
tary muscular tissue, the source of the contraction being outside the 
stomach, is at least probable. 

Is pyloric spasm unassociated with pain and with persistent vomit- 
ing, a common condition, or even an occasional condition in older 
children? It certainly clinically does not resemble the cases described 
as associated with gastric ulcer, 1 and gall-stone colic in which the 

1 Fairehilds, Iowa Med. Jour., Des Moines, 1910-11, xvii, 212. 



312 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

pain is excessive and vomiting not a marked symptom. Periodic 
pyloric spasm may occur at the menstrual period, 1 unassociated with 
any disease of the stomach, or with spasm in any other portion of the 
body, and under such conditions is probably a primary spasm of the 
pylorus, a motor neurosis. Lauder Brunton's observations tend to 
show that pyloric spasm may accompany migraine, and be a manifes- 
tation of a neurosis. 

A number of cases of infantile pyloric spasm have been followed 
up to the age of five years and older, and found to be in first-class 
health, and in quite a considerable number of such cases there is no 
neurotic family history. The clinician should not lose interest in 
these babies after they pass beyond the period of infancy, and an 
effort should be made to follow their subsequent histories, especially 
with reference to any gastric symptoms. 

Cases of infantile pyloric spasm have been kept under observation 
for years. 2 All the symptoms may persist until the third year, and 
the child may remain nervous and anemic for years afterward. In 
other cases, solid food can not be given until the child is three, or 
even five years old. In still other cases of spasm, vomiting may 
persist until the patient is four years old or older, and the peristaltic 
waves may continue until the child is over four years of age. 

Cases diagnosed as cyclic vomiting have come to autopsy 3 and the 
lumen of the pylorus has been found to be very small, with a distinct 
hypertrophy. In these cases the children may be four or five years of 
age, the symptoms of epigastric pain and vomiting having been 
present since birth, returning at irregular intervals of months, and the 
children being apparently perfectly well between the attacks. 

I do not mean to give the impression that cyclic vomiting and pyloric 
spasm are not two entirely different conditions, but to suggest the 
advisability of considering the possibility of pyloric spasm producing 
symptoms that resemble closely those of cyclic vomiting. 

What are the causes of the pylorospasm in infancy that disappears 
in later childhood? Half of these children are breast-fed, and it seems 
to me unnatural to claim, as does von Starck, that the unaccustomed 
presence of food in the stomach produces an irritation of the gastric 
mucosa and so causes the spasm. 

A clearer understanding of the etiology in infants may help us in 
the recognition and study of the condition in older children. 

ENTERALGIA OR COLIC. 

Colic is paroxysmal pain caused by a spasm of the intestinal muscles ; 
and, although merely a symptom of gastro-intestinal disorder, it is 
so common in infancy and early childhood that it merits special con- 
sideration. Artificially fed babies suffer much more from colic than 

» 

1 Hemmeter, Diseases of the Stomach, Ed. 3, p. 744. 

2 Heubner, Berlin, Therap. d. Gegenw., 1906, viii, 433. 

3 Proc. Roy'Soc. Med., London, 1909-10, hi, Sect, Dis. Child., 78. 



ENTERALGIA OR COLIC 313 

do the breast-fed, hut it is by no means infrequent when the feeding 

is apparently ideal. 

The most common cause of colic is gas in the stomach and intestines, 
which accumulates rapidly as a result of fermentation due to indiges- 
tion and improper feeding, especially when there is intolerance to 
sugar, or when the carbohydrate or protein content of the food is 
excessive. In many instances, air swallowed while nursing from 
the breast or bottle is also responsible for intestinal pain after 
feeding. 

Colic may occasionally be a symptom of far more serious import 
than in the cases mentioned, since it is present in appendicitis, obstruc- 
tion of the bowel, peritonitis, and intussusception. It may also be 
caused by intestinal parasites, by chilling of the abdomen, and by 
drinking ice-water. 

Symptoms. — The symptoms of colic need but little description. 
The child cries out in pain; its face is distorted, its legs are drawn 
up; the knees and elbows are bent, and the hands clinched. The 
abdomen is hard and tense, but there is no tenderness, and the press- 
ure of the warm hand in palpating brings relief. There is no fever; 
but the child may break into cold sweat during a paroxysm and turn 
pale, its extremities grow cold, and it may go into collapse. 

These symptoms usually appear shortly after the child is fed, caus- 
ing it to moan and cry until there is an eructation of gas from the 
stomach and discharge of flatus from the bowel, after which the pain 
disappears and relief is evident. The pain may sometimes be miti- 
gated by giving the infant some food as soon as it begins, but usually 
it returns in a short time. In carbohydrate indigestion colic does not 
set in until several hours after the first or second feeding. 

Diagnosis.— Simple colic will need to he differentiated from appen- 
dicitis, otitis media, and intussusception. The localized tenderness 
and rising fever which accompany appendicitis usually reveal the 
source of pain in that disease. In intussusception, there is early tumor 
formation, and the bowels are constipated, the discharges containing 
blood and mucus. If acute otitis media be present, and the child be 
watched closely, it will usually indicate in some way that the supposed 
colicky pain in the abdomen is really in the ear. Peritonitis may also 
be excluded by the severity of the vomiting and the short duration 
of the pain. 

Treatment. — The most effectual treatment of colic is to relieve the 
distention of the intestines by promoting the expulsion of the gas, 
and to prevent further fermentation and gas formation by careful 
regulation of the diet. The child or infant should lie on its belly and 
hot-water bags or hot poultices may be applied. An enema of warm 
water almost always brings relief, and warm peppermint-water should 
be administered by mouth. 

If the peppermint does not relieve the pain, we should not resort 
to alcohol or opiates, but the infant may be given a drop or two of 
Hoffman's anodyne, 1 or 2 grains of bicarbonate of soda, If) drops of 



314 DISEASES OF THE OASTRO-INTESTlNAL TRACT 

elixir of anise, or 5- to ID-drop doses of Wyeth's elixir of catnip and 
fennel. It is sometimes well to give a teaspoonfnl of castor oil or a 
tablespoonful of milk of magnesia to children who habitually surfer 
from colic; and if, during the nursing period, they are taken from 
the breast and held upright, at the same time being patted on the 
back, the gas will escape and the tendency to attacks of colic be 
greatly lessened. If the intervals between feedings are lengthened, 
and the amount of food is decreased for a short time, these attacks 
usually cease. The strength and quantity of the food may then 
be gradually increased until the child is taking ample nourishment. 
Strict attention should be paid to the clothing these children wear, 
in order to guard against any chilling of the abdomen, and to make 
sure that there are no constricting bands around the waist. 

HEMATEMESIS. 

Hematemesis is not an uncommon occurrence in childhood, though 
infrequent during infancy. True hematemesis may be due to the 
hemorrhagic diseases which affect the newborn, to gastric ulcer, also 
to scurvv, purpura, hemophilia, vicarious menstruation, acute leuke- 
mia, and splenomegaly, as well as to accidental causes. In some 
cases the blood is swallowed and then ejected from the stomach, 
thus simulating the hematemesis seen in breast-fed infants when the 
blood from cracked and fissured nipples is swallowed with the milk 
and then vomited. 

It also occurs in children who swallow blood from the nose, gums, 
or throat. Blood which is immediately ejected as soon as it enters 
the stomach is apt to be of a bright scarlet color; but it is dark 
and coffee-colored if it has remained there for any length of time. 
When passed by the bowel, blood always makes the stools black and 
tarry. 

Treatment. — If the blood actually comes from the stomach the case 
is one of true hematemesis, and the child should be put to bed and 
deprived of food and liquids until the bleeding stops. Calcium lactate 
may be given in 5-grain doses, three times a day, or adrenaline 
chloride in 1 to 1000 solution in 5-drop doses, three times a day. 

An injection of fresh human blood serum is by far the most effectual 
measure to stop the bleeding, and as much as an ounce may be given to 
an infant, three times a day, with no danger of untoward effects. Smaller 
amounts often fail to control the hemorrhage; therefore, if it be 
obtainable, the maximum dose should be given. Horse serum, diph- 
theria antitoxin or coagulose may be used instead of fresh human 
blood serum. Coagulose is supplied in 15 c.c. glass bulbs which con- 
tain 0.65 gram of desiccated powder, equivalent to 10 c.c. of human 
blood serum. Coagulose will keep for a long time without losing any 
of its properties. 



GASTRIC ULCER 315 

GASTRIC ULCER. 

Ulceration of the stomach is very rare before adult life, but during 
childhood is more frequently observed in infants than in older chil- 
dren. There may be but one small perforating ulcer or many areas 
of shallow ulceration which is hardly more than erosion. Follicular 
ulcers caused by acute gastritis are more common in infancy and 
childhood than in adult life. Tuberculous ulcers are exceedingly rare, 
yet they occur either as one large ulcerated area or several smaller 
ones. Acute ulceration of the stomach shows a distinct tendency to 
perforation, and usually appears at the cardia, while the chronic 
gastric ulcer which results in scar formation and cicatrical contraction 
is generally located near the pylorus. 

Etiology. — When a newborn infant suddenly develops a gastric 
ulcer, many good reasons incline us to believe it either of embolic origin 
or due to some other circulatory change, such as venous stagnation 
or ecchymosis. In older children the same etiological factors are active 
which are potent in adult life. In some cases chronic ulceration of the 
stomach and gastric erosions are thought to be secondary to catarrhal 
gastritis, while gastric ulcer is observed in association with the hemor- 
rhagic diseases of the newborn, with scorbutus, and with septicemia, 
and occasionally follows one of the acute infectious diseases. Con- 
genital ulceration of the stomach has been reported. 

Symptoms. — During infancy and childhood vomiting of blood and 
the passage of bloody stools are the only characteristic symptoms of 
gastric ulcer, and in the absence of these a diagnosis is impossible, inas- 
much as the additional signs and symptoms are simply those of gas- 
tritis. The pain may be mistaken for colic since, as a rule, it imme- 
diately follows the ingestion of food and causes vomiting; but if the 
amount of blood in the vomitus be small, as is frequently the case in 
follicular ulceration, it escapes notice and the true condition is not 
suspected. Blood vomited soon after a hemorrhage is scarlet-red, 
and practically unchanged; if it has been retained for any length of 
time in the stomach it is coffee colored, and when passed in the stools 
very dark and tarry. When a gastric ulcer is present, hemorrhage is 
often induced by active exercise or a heavy meal, and if the amount of 
blood lost is small, frequent hemorrhages, while unnoticed, may cause 
secondary anemia which develops rapidly and may be one of the first 
marked symptoms. The epigastrium is usually tender on palpation, 
although the pain may be referred to the back. Frequently there is 
an associated catarrhal gastritis. The bowels may be either loose or 
constipated. 

Diagnosis. — In children the diagnosis of gastric ulcer can frequently 
be made if there is vomiting of blood and melena, but when there is 
little or no hemorrhage the disease is recognizable only at postmortem. 

Prognosis. — The prognosis is often unfavorable, since death usually 
follows hemorrhage or perforation. In the absence of these compli- 
cations, and when the ulcer is situated at the cardia or the pylorus, 



316 DISEASES OF THE GASTRO-INTESTINAL TRACT 

cicatrization may ensue and cause stenosis and dilatation of the 
stomach. 

Treatment. — If gastric ulcer be suspected and the child is vomiting 
blood, it should be put to bed and kept there until all symptoms have 
subsided. Food and drink by mouth should be withheld, and nourish- 
ment given by rectum in the form of nutrient enemata. When thirst 
is extreme pieces of ice may be given the child to suck, and small sips 
of water allowed. As improvement sets in, weak broths should be 
added to the diet, and the quantity and strength of the food gradually 
increased until the normal diet is established. Bleeding may be so 
severe that the child will sink into collapse and die before any measures 
to control it can be taken. If stimulation is required, camphorated 
oil, administered in one to five doses hypodermically, or black coffee, 
2 to 6 drams, with 20 to 80 drops of brandy, injected into the rectum, 
will frequently be of service. Gelatin in dram doses, given by mouth 
every hour, has controlled bleeding in not a few cases. 

Although drugs are usually ineffectual, adrenalin chloride solution, 
1 to 1000, in 1- to 3-drop doses every hour, or bismuth subnitrate, 
in 10-grain doses every three hours, may be tried. The injection of 
human serum, one ounce of which may be used subcutaneously in an 
infant, will often be followed by cessation of bleeding. Excepting sur- 
gery this is, perhaps, the most reliable method of checking internal 
hemorrhage. Injections of one to three ounces of human blood, the 
blood being withdrawn from the donor by means of a sterile syringe 
and immediately injected into the patient, have a decided influence 
in controlling hemorrhage. If human serum or whole blood cannot 
be quickly obtained, horse serum, or diphtheria antitoxin which con- 
tains horse serum, can usually soon be secured and injected. The 
results from these injections are often most satisfactory. 

Pain is sometimes so severe as to require the hypodermic adminis- 
tration of morphine, or the rectal injection of chloral, bromides, or 
paregoric, which should be given in double the dosage prescribed b} T 
mouth. Hot fomentations are also of service in relieving epigastric 
pain; but if there is hemorrhage, cold applications are indicated. Per- 
foration of the stomach demands immediate surgical intervention; 
but the mortality rate from such operations is very high, even though 
a competent surgeon operate immediately on a case in which perfora- 
tion has been diagnosed. 

CHRONIC INTESTINAL INDIGESTION. 

Chronic intestinal indigestion is usually associated with chronic 
gastric indigestion, and occurs, as a rule, in children who have had 
repeated acute attacks of indigestion. 

Etiology. — It is most common during infancy, and may be either 
congenital or acquired. The congenital form is due to an inherent, 
weakness of the intestinal digestive power, while the acquired type is 
usually brought on by a prolonged period of injudicious feeding. Chil- 



CHRONIC INTESTINAL INDIGESTION 317 

dren whose health is undermined by syphilis, tuberculosis, rachitis, 
or other chronic disease, are especially liable to it, and it may follow 
a severe attack of scarlet or typhoid fever, diphtheria, or other acute 
infection. In the majority of cases, chronic intestinal indigestion is 
observed in the children of the poor who are segregated amid unhy- 
gienic surroundings, and who do not receive proper care or food. The 
breast-fed baby rarely suffers unless the mother is extremely careless 
and the infant is nursed without regard to regularity, but the con- 
dition is very common in bottle-fed babies, and constitutes one of the 
most difficult affections which the practitioner is called upon to treat 
in infancy and childhood. 

Perhaps the most common source of trouble in artificial feeding is 
the faulty composition of the feeding mixture which results in either 
fat, carbohydrate, or protein indigestion. Overfeeding is another 
frequent cause of trouble, due to the mother's habit of giving the baby 
the bottle whenever it. cries to quiet it. Whether the food be too rich 
in one or all constituents, or too great a quantity be given, the result 
is an overtaxing of the intestinal digestion which, if greatly prolonged, 
weakens the digestive function and produces a state of chronic 
indigestion. 

While chronic digestive disturbances are especially common during 
the first year of infancy, intestinal indigestion is not uncommon in 
older children. Here the usual cause is an excess of carbohydrates 
from overindulgence in cakes, candies, pastries, and other rich and indi- 
gestible foods. In some cases the condition arises because the child is 
fed for a year or two after weaning on too large a proportion of cereals, 
bread, and potatoes. Condensed milk and patent foods are often the 
cause of infantile indigestion, for they are rarely prepared properly, 
and, although the child's stomach usually tolerates them for a short 
time, their continued use sets up digestive disturbances which are hard 
to correct. Regularity in feeding is just as important with older chil- 
dren as with infants, and the habit of eating between meals, which is 
so common during childhood, often gives rise to chronic intestinal 
indigestion, because of the continuous strain upon the digestion. 

Pathology. — As a rule there are no clearly defined pathological lesions 
of the intestines, since this condition is usually a functional disturb- 
ance, therefore is not accompanied by organic changes. In protracted 
cases, evidences of a low-grade catarrhal inflammation of the intestinal 
mucosa may be found, and, in addition, the lymphoid tissue of the 
intestines and mesenteric glands may be enlarged and swollen. 

Symptoms. — There is usually a history of injudicious feeding or other 
dietetic error, as a result of which the infant has repeatedly had acute 
attacks, of gastro-enteritis. Partial recovery has followed, and then 
the series of acute attacks has yielded to a state of chronic and persis- 
tent indigestion. The weight at first remains stationary, then begins 
to fall, and other signs of impaired nutrition, such as anemia, subnormal 
temperature, failing circulation, irritability, restlessness and disturbed 
sleep, develop. The bowels are usually loose, diarrhea alternating 



318 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

with occasional and irregular periods of constipation. The stools 
are usually a greenish color, and composed of undigested food, as is 
shown by the presence of fat and protein curds. 

In some cases they are extremely watery, highly acid, and frothy, and 
are passed with much flatus, which indicates a disturbance of carbo- 
hydrate digestion. There is generally a moderate amount of mucus 
in the stool in the form of shreds which may surround the fecal masses. 
The stools average five or six daily, but during acute exacerbations 
the infant may have from twelve to twenty a day. Although constipa- 
tion usually alternates with diarrhea in intestinal indigestion, yet now 
and then the constipation stubbornly persists, and in these cases the 
stools are hard, dry, covered with mucus, and may be passed with 
extreme difficulty. 

Intestinal colic and flatulence are much more distressing in the cases 
that are constipated than in those with diarrhea, and fever is more 
likely to be present. Vomiting occurs only occasionally, and is never a 
constant feature of the disease. The appetite may be good or impaired, 
but is usually capricious; the tongue is always coated; the breath 
has a fetid odor. In both infants and children the abdomen is dis- 
tended, protuberant, and tympanitic; but, as a rule, there is little or no 
tenderness. The skin is usually dry, the extremities are cold, the tem- 
perature is subnormal except during acute exacerbations, and when 
the child is constipated. An infant may remain in this condition almost 
indefinitely, but its development is retarded, both mentally and physi- 
cally, so that it may be two or three years of age before it can walk or 
talk. 

In the older child the symptoms of chronic intestinal indigestion are 
somewhat different from those in infants. Constipation is present 
instead of diarrhea; but in exceptional cases the bowels may be loose. 
The stools are hard, either gray or white and of foul odor. Colic is 
sometimes severe, and there is usually much flatulence. The appetite 
may be good or poor, but is usually either impaired or so capricious 
as to fail to provide sufficient nourishment. In consequence these 
children become thin, pale, and anemic, with dry skin, sunken eyes, 
and cold extremities. They are usually listless and apathetic, show 
no desire to play, and are easily fatigued. The nervous system is some- 
times markedly affected, causing the child to be extremely irritable and 
cross. In some cases attacks of syncope and dizziness are quite com- 
mon. Convulsions are rare; but acute attacks of vomiting with severe 
headache are not infrequent. 

The absorption of toxins from the intestine produces a mild but con- 
tinuous fever with occasional sharp rises in temperature when the tox- 
emia becomes more profound. The urine is high colored, concentrated, 
and, as the result of intestinal stupor, contains an excess of indican. 
In older children the skin frequently shows evidence of urticaria or 
other lesion due to the gastro-intestinal disturbance while in infancy 
eczema and intertrigo on the thighs and buttocks are a common result 
of the irritating action of the stools. 



CHRONIC INTESTINAL INDIGESTION 319 

Diagnosis. — In the majority of cases the diagnosis of chronic intes- 
tinal indigestion is easily made if the symptoms and history of con- 
tinued digestive derangement are taken into consideration; but in 
order to treat the condition successfully its exact nature must be 
ascertained. The character of the stools will be a clue to the form of 
indigestion present, and a microscopic examination of the feces will 
determine whether there is intolerance to fat, proteins, or carbo- 
hydrates. In fat indigestion the bowels are loose, semisolid, of a 
yellowish-green color, and contain fat curds. Carbohydrate indigestion 
is indicated by very loose or watery and highly acid movements, which 
irritate the buttocks and are passed with much flatus. If the bowels 
are constipated, the infant is usually suffering from protein indigestion, 
and large casein curds are found in the stools. Colic is apt to be more 
severe in this form of indigestion, and there is more or less vomiting. 
In some cases tuberculosis may be suspected, but examination of the 
lungs is negative, there is no cough, and the temperature range is 
unlike that of tubercular infection. 

Prognosis. — The prognosis depends upon the vitality of the child, 
the duration of the disease, and, to a certain extent, upon the mode 
of treatment and the thoroughness with which it is carried out. As 
a rule, the outlook is more favorable in breast-fed infants and in older 
children; but, at the best, improvement is very slow and recovery gradual. 

Treatment. — The most important phase of treatment is the regula- 
tion of the diet. When the infant is breast-fed, if the stools show an 
excess of fat, which indicates that the milk is too rich, the time the baby 
is allowed to nurse should be shortened, and an ounce or two of water 
given the child in addition to each nursing to dilute the mother's 
milk. The diet of the mother may also be restricted. The baby should 
be nursed at regular intervals of not less than three hours. In excep- 
tional cases it may be necessary to pump the milk from the mother's 
breasts and skim it before giving it to the child; but under no cir- 
cumstances should any other food be substituted for the milk of the 
mother unless a suitable wet-nurse be found. If the child is bottle- 
fed, and a wet-nurse can be procured, the giving of human milk forms 
an easy solution of the dietetic problem. 

In every case it is advisable at the beginning of treatment to withhold 
all milk for a day or two, and then, if it be necessary to give a feeding 
mixture, the formula should contain a very low percentage of fats 
and proteins. The amount of fats, carbohydrates, or proteins to be 
given an infant should always depend upon the character of the stools ; 
and if intolerance to any one of these constituents is evident the amount 
of that one ingredient to be put into the feeding mixture should be 
decreased until improvement in digestion is noted. 

As a rule, it is well to give a fat-free mixture at the onset of treatment 
to babies who are exclusively bottle-fed, and to stop all starchy food 
in children two or three years old who are on a mixed diet. Bottle- 
fed babies should be given dextrinized gruels and cereals, fat-free milk 
that has been peptonized, fat-free whey, and albumen-water in small 



320 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

quantities at frequent intervals as a substitute for the milk mixture. 
As the child improves fat may be very slowly added, \ to J per cent, at 
a time, and the percentage of sugar also increased as the digestive 
power of the patient improves. 

A strong tendency prevails to substitute patent infant foods when 
milk is not borne well; but in these cases they are apt to do harm and, 
as a rule, it is wiser to resort to Eiweiss milk, broths, buttermilk, or 
malt soup formulas. In older infants broths, beef juice, scraped meat, 
fruit juices, and a little dry bread, or a few crackers may be given; 
but all starchy foods should be much restricted for at least a year. 
Children who have been allowed to eat between meals and indulge 
in sweets and pastries should be kept upon a very plain but nutritious 
diet for a month or two, and allowed to eat only at meal time. The 
child of two years may be fed five meals daily, the child of three or 
four should eat four times a day, and at five years three meals are 
sufficient. As a rule, cakes, candies, pastries, potatoes, hot bread, 
fried food, and raw fruits should be prohibited in the dietary of children 
with weak digestion; but beef, lamb, chicken, fish, eggs, and rice are 
usually well digested. 

The medicinal treatment of chronic intestinal indigestion should 
consist of an initial purgative dose of castor oil, repeated at intervals 
during the course of the disease, and the bowels kept open by the use 
of a mild laxative to insure at least one passage a day. In the cases 
with diarrhea it is well to administer bismuth subnitrate in 5- to 10- 
grain doses, also tincture of nux vomica in one- to three-drop doses 
for its tonic effect on the system. The syrup of the iodide of iron is 
also of service during convalescence, given in full tonic doses of 10 to 
30 drops, according to the age of the child. Intestinal irrigations are to 
be resorted to only during acute exacerbations ; for, if too long continued, 
they are liable to irritate the colon and do more harm than good. 

The general treatment of these children should be carefully carried 
out. The clothing must be warm enough to protect the child from 
changes in temperature. An abdominal binder gives support to the 
distended abdomen, and should be worn continuously. The impor- 
tance of the daily bath should be emphasized, and a cold sponge each 
morning is most beneficial unless the child is too weak for it, as shown 
by coldness or blueness of the extremities after the brisk rubbing 
which should always follow a cold sponge. 

If sent to the mountains or seashore, children improve rapidly; but 
when such change of environment is impossible, abundance of fresh 
air should be given the child by keeping it out of doors during pleasant 
weather and having the sleeping room well ventilated at night. 

CHRONIC ILEOCOLITIS. 

Chronic ileocolitis is induced either by severe attacks of acute ileo- 
colitis or by chronic intestinal indigestion; but the most severe cases 
are those which follow acute ileocolitis. 



CHRONIC ILEOCOLITIS 321 

Etiology. — An acute attack of ileocolitis usually becomes chronic 
because of poor management of the diet and lack of hygienic care. In 
a few instances it may follow typhoid fever, pneumonia, and other 
acute infectious diseases, especially scarlet fever and measles. After 
severe and protracted cases of chronic intestinal indigestion, we find 
at postmortem chronic inflammation of the ileum and colon, which is 
the result of constant irritation of the intestinal mucosa by bacterial 
toxins, fermentation, and the products of decomposition. 

Pathology. — The most common pathological lesions found in the 
intestines are a change in color to dull gray; slight pigmentation; 
swelling of the lymphoid tissue; and a thickening of the mucosa of 
the ileum and colon. In addition to these evidences of chronic catarrhal 
inflammation of the mucosa, there are hemorrhagic and ecchymotic 
areas scattered throughout the walls of the bowels, while an excessive 
secretion of mucus covers the mucosa. In severe and protracted cases, 
a section of the intestinal wall studied under the microscope will show 
the tubular glands of the mucosa to be atrophied, and the villi and 
follicles undergoing degenerative changes. The mesenteric glands are 
swollen and enlarged, and occasionally show caseation in the centre. 
Ulceration is rare in chronic ileocolitis; but at postmortem follicular 
ulcers are occasionally found, and less frequently large superficial 
ulcers. 

Bronchopneumonia and hypostatic congestion of the lungs are the 
most frequent accompanying diseases. In severe cases there is cloudy 
swelling of the heart muscle, also fatty degeneration of the liver cells. 
Nephritis is rare; but in most cases the renal epithelium is found in a 
state of cloudy swelling. 

Symptoms. — In the majority of cases the most important symptoms 
of chronic ileocolitis are constant diarrhea and progressive emacia- 
tion. The stools are usually yellowish green or brown in color, and 
number three to six a day. They consist of undigested food and mucus, 
but there is rarely any blood except in ulcerative cases. The abdomen 
is generally distended and tympanitic; and there may or may not be 
a great amount of colic and flatulence. Tenesmus is not as severe, 
nor prolapse of the rectum as common, as in acute ileocolitis. 

In many cases the appetite is unaffected and the child rarely vomits; 
but emaciation is continuous and progressive, and the face acquires 
a wizened and pinched expression. The skin is dry and coarse, and 
may be eczematous about the anus and genitalia. The constitutional 
symptoms become aggravated as the disease progresses, and in 
advanced cases the eyes are sunken, the fontanelle is depressed, the 
temperature subnormal, the heart beat weak and rapid. The child 
becomes so exhausted that it rarely moves, and the cry is merely 
a whine. The feet and hands are cold because of the poor circulation, 
and the extremities may become edematous. At the onset of the disease 
the child is fretful, cross, and irritable, perhaps crying continually, 
and throughout the attack it is nervous and peevish. The nervous 
symptoms are varied, delirium and stupor being common, but con- 
21 



322 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

vulsions are rare. Death usually supervenes as the result of some 
complication or intercurrent disease, such as bronchopneumonia, or 
one of the exanthemata. 

Diagnosis. — Chronic ileocolitis may simulate general tuberculosis, and 
the child should be thoroughly examined with the view of excluding 
this disease as an underlying factor. Absence of fever and of demon- 
strable foci in the lungs and a negative von Pirquet reaction will usually 
preclude the possibility of tubercular infection. Syphilis should be 
excluded by careful inquiry into the history of the mother and by blood 
examination if necessary. Rachitis presents such characteristic physi- 
cal signs that its presence is perfectly obvious. It is practically impos- 
sible to form any idea of the extent of the ulceration, but the catarrhal 
form of chronic ileocolitis may be diagnosed by the absence of blood 
in the stools and the comparatively mild character of the disease. 

Prognosis. — The prognosis in the severe cases is, as a rule, unfavor- 
able, and is rendered still more so by existing systemic diseases or by 
the poor environment so often observed in this disease. The outcome 
also depends upon the vitality of the child when brought under obser- 
vation, its age, and the severity of the attack. Infants may die, but 
the chances of recovery are much more favorable in older children. 

Treatment. — Whenever possible these children should be removed 
from their unhygienic surroundings and sent to the country or sea- 
shore; or, at least, should be given the advantage of plenty of fresh 
air, for improvement is much more rapid when the child lives under 
sanitary conditions. Much depends upon the thoroughness with which 
treatment is instituted; hence it is important that the mother of the 
child carry out orders implicitly or that she secure a reliable trained 
nurse. 

An initial purgative dose of castor oil should be given, and there- 
after the bowels should be moved every day; milk of magnesia may be 
given to infants, and cascara sagrada to older children. Colonic irri- 
gations should only be used during the acute exacerbations; for, if 
employed continuously, they may irritate the rectum and colon and 
cause an increased secretion of mucus by aggravating the inflamed 
mucosa. When by absorption an accumulation of fecal matter gives 
rise to autointoxication, the colon should be > irrigated with normal 
saline solution, after which several ounces of a 2 per cent, tannic acid 
solution should be injected and allowed to remain for fifteeen to twenty 
minutes. 

Regulation of the diet is perhaps the most important part of treat- 
ment. The feeding should be carefully supervised throughout the 
attack and for months after recovery has taken place, because indiscre- 
tions in diet cause relapses, one of which may prove fatal. Mother's 
milk should be given whenever possible. If the baby is bottle-fed, milk 
should be withheld for several days, and albumen-water, dextrinized 
cereals, or weak broths substituted. After improvement sets in pep- 
tonized milk, Eiweiss milk, malted soups, or buttermilk may be tried 
in lieu of ordinary milk. 



INTUSSUSCEPTION 323 

When it seems wise to give milk, a weak formula containing 2 per 
eent. of fats, 4 per cent, of sugar, and 1 per cent, of protein should be 
used for the infant of six months, and weaker formulas for younger 
babies. These mixtures may gradually be made stronger as the diges- 
tive power of the infant increases. An arrest of the progressive loss 
of weight is a favorable indication, and a steady gain in weight may be 
regarded as a sign of ultimate recovery, provided there are no relapses. 

INTUSSUSCEPTION. 

Intussusception is the slipping of one portion of the intestine into 
another, and is one of the causes of acute obstruction of the bowels. 
The most common site for this affection is the ileocecal region, although 
it may occur in any part of the intestinal tract. There are three ana- 
tomical forms: the enteric, in which one portion of the small intestine 
is invaginated into another section of the small bowel; the colic, in 
which the large bowel is invaginated within the large bowel; and the 
ileocecal, caused by the invagination of the ileum and cecum into the 
colon. 

Etiology. — Intussusception is a rare disease, but occurs much more 
frequently in childhood and infancy than in adult life. The majority 
of cases are seen in children less than a year old, and males babies are 
affected more frequently than females. Its exact cause is unknown. 
Several theories have been advanced, the most probable of which are 
based upon the irregular muscular action (spasmodic in character) 
of the intestinal wall and paresis of the muscular coats of the bowel. 
In a certain number of cases Meckel's diverticulum and other abnor- 
malities have been found, and exceptionally there is a history of ante- 
cedent digestive disturbance and inflammation of the bowels. Ty- 
phoid fever may also be followed by intussusception; here the weakened 
condition of the intestines is probably a factor in its causation. In 
most cases, however, the patient is a healthy and well-noursished infant 
who has never been ill; therefore the disease is caused more frequently 
by overactive and spasmodic intestinal movements than by lack of 
muscular tone. A history of abdominal injury is occasionally elicited; 
but the relation between trauma and intussusception has not been 
established. 

Pathology. — Invagination takes place from above downward, hence 
the distal portion of the affected intestine is found drawn over the proxi- 
mal end. At the site of the lesion we find three layers of bowel: the 
outer, or intussuscipiens, which receives the invaginated portion; the 
internal, or entering layer; and the returning layer. These last two 
layers are invaginated and enclosed by the first, and are known as the 
intussusceptum. The intussusceptum is thickened and congested, 
and in the course of a few days adhesions form between this and the 
enclosing layer of intestine. Obstruction of the bowel is the result of 
congestion and edema, and the blood supply is cut off by traction on 
the mesentery which, if unrelieved, causes gangrene and sloughing. At 



324 DISEASES OF THE GASTRO-INTESTINAL TRACT 

postmortem there is frequently found a condition known as agonal 
intussusception, in which multiple intussusceptions have taken place 
throughout the intestinal canal. 

Symptoms. — In the usual form of the disease the symptoms develop 
suddenly, and are so severe that they may cause shock and collapse. 
Vomiting is persistent and violent, and occurs earliest in the attack 
when the lesion is high up in the small bowel. Pain is severe and comes 
in paroxysms, during which the child lies on its back with the thighs 
drawn up on the abdomen. There are no prodromes; therefore healthy 
children are sometimes attacked while nursing or asleep, and may be 
quickly prostrated or go into collapse. The bowel discharges are loose 
and evacuated with much tenesmus. After the fecal matter below 
the site of the obstruction has been discharged, the stools are composed 
of blood and mucus. 

The temperature becomes subnormal; the face is pale; the pulse is 
rapid and feeble. Pain subsides when gangrene sets in, but vomiting 
continues, although it is not as a rule stercoraceous. The bowels 
usually become absolutely constipated about the third or fourth 
day. 

The abdomen, at first, is neither tender nor distended, but so relaxed 
that abdominal palpation is easily accomplished. During the first 
day or two the presence of a tumor is readily ascertained but, later on, 
the abdomen becomes distended and tympanitic, and, if peritonitis 
develop, is tender and rigid throughout. 

In a considerable proportion of the cases a tumor may be detected 
by digital examination through the rectum, and it should always be 
sought for, since it is a valuable aid to diagnosis. The mass is sausage- 
shaped, from four to six inches long, and of putty-like consistency. 
It is rendered more prominent by abdominal examination or by an 
attack of severe pain. It may be located in any part of the intestinal 
tract, and is sometimes found projecting from the anus. 

Intussusception generally runs an acute course. If the obstruction 
is not relieved prostration becomes extreme, the temperature ascends 
because of the toxemia and peritonitis, the child's face assumes an 
anxious expression, and it finally dies in collapse. 

Diagnosis. — The diagnosis of intussusception can be made with cer- 
tainty in any case where there is a history of sudden severe pain, 
vomiting, and bloody stools, and when a tumor can be felt along the 
intestinal tract. The sudden onset, the violence of the symptoms, the 
absence of fever, the shock, sharply differentiate this disease from ileo- 
colitis, gastro-enteritis, or other intestinal inflammation. 

Prognosis. — During infancy an attack of intussusception runs a rapid 
course; and, in the majority of cases, unless relieved spontaneously 
or by operation, will terminate in death within five days. The earlier 
the operation and the older the child the better the outcome. Sub- 
acute and chronic cases offer a more favorable outlook than do those of 
the acute type, in which the chances of recovery are reduced consider- 
ably by each succeeding day of the disease, 




Fig. 30. — Drawing of specimen from a case of intussusception in an infant. In 
the diagram the letters have the same signification. A A, colon; B, point where the 
ileum enters the intussusception. The letter B points directly within the intestinal 
lumen. A probe passes in at B and comes out at C. The diagram illustrates the course 
which it must pursue. D is the appendix; E, point of constriction of the ileum; F, 
point of slight eversion where the serous coat turns to pass within the bowel: G shows 
the line of constriction in the ileum caused by the ileocecal valve. The specimen has 
been pulled through the valve to show this line of constriction and the gangrenous 
mass of intestine beyond extending from G to C. This point of constriction in the 
diagram is indicated by a slight depression at G. H, I and J show the line of attach- 
ment, of the mesentery. Between H and /, and extending slightly beyond the line I . 
is a fold produced by pulling the intestine through the ileocecal valve sufficiently far 
to show the gangrenous process. 



326 DISEASES OF THE GASTRO-INTESTINAL TRACT 

Treatment. — Surgical intervention should immediately follow the 
making of a diagnosis; for, if the gut is not gangrenous, the condition 
may easily be corrected by a laparotomy. Attempts at reduction by 
other measures are justifiable, but should not delay operation. Warm 
water may be injected into the colon, and, if no force is used, will do 
no harm. Inflation of the intestines by air under pressure is a danger- 
ous procedure, and, if employed, the air should be introduced very 
slowly. The child should be inverted when these methods of reduction 
are being tried. If, perchance, reduction is accomplished, no food 
should be allowed for from twelve to twenty-four hours, the bowels 
should be kept quiet by suitable doses of paregoric, and no cathar- 
tics or purgatives given for at least a week. 

CHRONIC CONSTIPATION. 

Chronic constipation, which is quite common in infancy and child- 
hood, is characterized by a failure of the bowels to move regularly, 
and by stools which are smaller than normal, very dry, and passed 
with much difficulty. An infant whose bowels are regular should have 
two or three movements daily, and the older child at least one stool 
a day. 

Etiology. — Constipation in the breast-fed infant is usually due either 
to a deficiency in the quantity of food or a deficiency of fat in the breast 
milk. These two factors must also be considered in the constipation of 
artificially fed babies; in addition there may be in the milk formula an 
excess of protein which, in itself, will result in hard, dry stools. Infants 
are all predisposed to constipation because of the position of the intes- 
tines during infancy; for situated, as they are, mainly in the pelvis, 
the great length of the large intestine in proportion to the size of the 
child's pelvis results in multiple flexures which retard to a great extent 
the movement of the fecal contents, and favor the absorption of the 
liquid portion of the stool, making the mass hard and dry. 

Atony of the intestines is a frequent cause of constipation in children 
who suffer from rachitis, malnutrition, anemia, tuberculosis, or any 
other chronic disease. In the acute infections, owing to the reduction 
in body fluid caused by fever, the stools are often hard and dry. Occa- 
sionally a steady milk diet will constipate, especially if no water is 
given, and in older children a diet lacking in residue, as would be the 
case if vegetables and fruits were restricted or omitted, will tend to 
produce constipation. In rare cases constipation will prove to be due 
to an organic cause, such as stricture of the anus, imperforate anus, 
anal fissure, proctitis, or hemorrhoids. In some families there undoubt- 
edly exists a hereditary predisposition to defective musculature of the 
bowels, which manifests itself early in life by stubborn chronic consti- 
pation in the child. 

Symptoms. — The most common indication of constipation is a diminu- 
tion in the normal number of bowel movements; but in some cases, 
while the number of stools is normal, they are very hard, dry, and 



CHRONIC CONSTIPATION 327 

smaller than they should be, Indicating that the waste products of the 
intestines are not all being excreted. In constipation, evacuation of 
the bowels is usually attended by much pain and straining which may 
lead to inflammation of the rectum and the passage of blood and mucus 
in the stools. If, for an unusual length of time, the bowels are insuffi- 
ciently evacuated, constitutional symptoms appear and the child 
becomes restless, feverish, nervous, and irritable, and may complain 
of persistent abdominal pain. The tongue is heavily coated, the breath 
foul, and all desire for food is lost. 

Diagnosis. — Constipation in itself is but a symptom the underlying 
cause of which should be sought, and the diagnosis of this primary 
condition is sometimes extremely difficult. 

Prognisis. — The prognosis of chronic constipation depends largely 
upon the cause; as a rule, it is very resistant to treatment and difficult 
to correct. 

Treatment. — The most important point in the treatment of chronic 
constipation is to ascertain the cause and remove it. If there is mus- 
cular atony of the intestines, due to constitutional dyscrasia, an effort 
should be made to build up the child's general health by careful regu- 
lation of the diet and the administration of such tonics as cod-liver 
oil, or drop doses of the tincture of mix vomica; in addition, special 
attention should be directed to the treatment of the underlying disease, 
whether tuberculosis, syphilis, or rachitis. Inasmuch as faulty diet 
alone is responsible for many cases of constipation, the quantity, 
strength, and quality of the food should always be carefully investi- 
gated and adjusted, although the results obtained are not always as 
encouraging as might be expected, probably because of secondary 
atony due to prolonged distention of the bowels. 

In breast-fed infants constipation is usually due to insufficient food 
or to a deficiency of fat in the mother's milk; therefore the nursings 
should be supplemented by artificial food in carefully prepared for- 
mulas or by additional breast milk from a wet-nurse. If the amount of 
food is insufficient and the milk is also poor in regard to its fat content, 
an effort should be made to improve the quality by increasing the 
amount of fat in the mother's diet. This, however, often fails to raise 
the fat content, so that it may be necessary to give a dram or two 
of cream before each nursing. In artificially fed babies who suffer 
from constipation the formulas and mixtures should be analyzed to 
ascertain if the fat content is not too low, and to reduce the per- 
centage of protein if in excess. A steady milk diet in later infancy, 
supplemented at times by the addition of oat meal gruel, orange or 
prune juice, or an occasional baked apple, will often correct or prevent 
constipation. 

With older children if the food does not leave enough residue to force 
the bowels to move regularly, the amount of fruit and vegetables 
should be increased. In regulating the diet of constipated infants 
and children so as to secure the laxative action of certain articles of 
food, the mistake is too often made of overdoing the matter; hence 



328 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

the artificially fed infant, in particular, is sometimes given as high as 
6 per cent, of fat mixtures in order to facilitate bowel evacuations, 
notwithstanding the fact that to raise the fat content above 4 per cent, 
will tend to constipate. The older child, too, is stuffed with fruits and 
cereals which overtax the stomach and intestines, not only producing 
obstinate constipation but chronic gastro-enteritis as well. Too often 
flatulent dyspepsia is begun in infancy in consequence of the frequent 
administration of cane sugar or oatmeal for the relief of constipation 
when the judicious use of specially prepared carbohydrates, such as 
Mellin's food or Horlick's malted milk given once or twice a day, 
is all that the infant requires to insure regularity of the bowels. 

In some children constipation is due largely to a lack of proper train- 
ing with regard to the bowels. As soon as it can sit up, the infant should 
be placed upon the chamber each morning after its first nursing, and 
if this practice is continued throughout infancy and early childhood 
a habit is formed which will persist through life. The school child 
should not be allowed to depart from the house in the morning until 
an effort has been made to evacuate the bowels, and schools should 
be so conducted that children have an opportunity of using the toilet 
whenever necessary, instead of being compelled to suppress this desire 
as is often the case. Water may always be given freely to the consti- 
pated child. In the treatment of chronic constipation, particularly, 
it is very beneficial to take a glassful before breakfast and at night 
before retiring. 

The use of enemata and suppositories is so liable to be abused that 
we frequently find in them a cause of, rather than a remedy for chronic 
constipation, since by habitually resorting to them the bowel becomes 
so accustomed to the powerful local stimulus produced that there is 
little or no response to natural stimulation alone. If only occasionally 
employed, however, they are of unquestionable value in securing evac- 
uation of the lower bowel when the purgative action of drugs is not 
desirable. In infants, especially, the simple expedient of inserting 
a cone of Castile soap into the rectum will cause the bowels to move, 
but the mother should not make a practice of this, as it may give rise 
to severe irritation of the rectum and anus. Glycerin suppositories 
are far more irritating than cones of soap, hence should only be used 
occasionally, and suppositories containing drugs are rarely of any value 
in infancy and childhood. 

Furthermore, enemata, while they are always effectual in giving 
temporary relief, should never be used frequently or indiscriminately, 
since they have a tendency to balloon the rectum, also to favor the 
accumulation of feces, and may cause atony of the bowel, thus greatly 
aggravating the constipation. If, however, the amount of fluid injected 
is but small, dilatation of the rectum is not likely to happen. For this 
reason it is advisable to inject an ounce of sweet oil or olive oil, or twice 
that amount of warm soapy water, rather than to wash out the rectum 
and colon with a half-pint or more of plain water or saline solution. 
Greater activity on the part of the infant or child should be encouraged 



CHRONIC CONSTIPATION 329 

as a valuable adjunct to treatment, and massage of the abdomen, 
especially along the course of the colon, is often beneficial. 

Constipation which is due to a local lesion of the anus or rectum 
depends for its relief upon the cure of that condition. If there be 
spasmodic contraction of the anus with no apparent organic lesion, 
such as fissure in ano, etc., sodium bromide in 2-grain doses or tinc- 
ture of belladonna in drop doses may be given the infant, and warm 
applications made locally. Stricture of the anus requires dilatation 
either by the finger or by more forcible divulsion, and fissure in ano 
is best treated by keeping the bowels loose, and anointing the lower 
part of the rectum and anus with unguenti zinci oxidi, unguenti 
hydrargyri, or a simple boric acid ointment. 

Electricity is the least valuable of all therapeutic measures in the 
treatment of constipation, and therefore is practically to be regarded 
as a last resort, and of service only in those cases where constipation 
is due solely to atony of the intestinal musculature. The galvanic 
current is more effectual than the faradic; when employed, one elec- 
trode should be placed in the rectum and the other passed over the 
colon. If it is desirable to use the faradic current, one electrode may 
be placed over the spine and the other passed with pressure over the 
abdomen along the course of the colon. While neither electricity, 
massage, nor hydrotherapy in the form of the cold morning bath, if 
used alone, is effectual in the treatment of chronic constipation, yet 
the judicious combination of these measures with an occasional enema, 
persevered in faithfully for several weeks, will in many cases yield 
most gratifying results. 

Medicinal treatment of constipation is a rather unsatisfactory and 
objectionable mode of correcting it, since drugs are of merely temporary 
service at the most, and if their use is prolonged the bowels become 
tolerant to all but massive doses, and it becomes impossible to secure 
a movement by any of the other methods suggested. If used at all, 
drugs should be given only occasionally during the course of more 
effectual methods of treating the condition, and the physician should 
aim gradually to lengthen the interval between doses, as well as to 
reduce the amount of the drug given. Now and then a course of calo- 
mel, 1 grain in divided doses, may be given the child of two or three 
years whose stools are grayish white. If there is atony of the muscular 
coat of the bowels, tincture of belladonna or tincture of nux vomica 
should be administered in drop doses for its stimulating effect. Cas- 
cara sagrada is, theoretically, the best medicinal agent if drug treat- 
ment is to be continued for any length of time since, in addition to its 
purgative action, cascara has a tonic effect on the bowels. The dose 
of the fluidextract is from two to ten drops according to the age of the 
child, and the elixir may be given in one-half to one teaspoonful doses. 
Maltine and cascara is very widely and wisely used. Aside from being 
an agreeable preparation, this is a valuable adjunct to treatment if 
administered properly, since it tones up the whole system in addition 
to its beneficial action on the bowels. Rhubarb, either in the form of 



330 DISEASES OF THE GASTRO-INTESTINAL TRACT 

the aromatic syrup or the mixture of rhubarb and soda,, is frequently 
given to children, but should be used cautiously since its continuous 
administration may aggravate the constipation. The same advice 
applies to the prescribing of senna, either in the form of the infusion, 
of which a half-ounce three times a day is the proper dose for a child 
of three years, or as the syrup, which is administered in 10- to 20-drop 
doses. 

If colic and flatulence are present salines are indicated, and 10 to 
30 grains of sodium phosphate should be given daily in cold water 
before the morning meal. This, however, should only be continued 
until the child's bowels move' every day after breakfast, and then the 
dose should be gradually reduced until the drug can be withheld alto- 
gether. Olive oil in dram doses is frequently sufficient to cause an 
evacuation of the bowels in the young infant, and does not gripe as 
does castor oil. Liquid petrolatum, liquid albolene, and Russian min- 
eral oil, if pure, are also preferable to less inert agents, since their action 
is for the most part mechanical. The dosage of any of the mineral oils 
is from 15 to 100 drops. If given in milk their presence is unsuspected. 
For bottle-fed babies, milk of magnesia is quite a popular laxative, 
a teaspoonful being added to the feeding mixture. In most cases it 
acts very well; but in common with all other drugs used for chronic 
constipation it should be given only temporarily, and should be dis- 
continued as soon as possible. 

INCONTINENCE OF FECES. 

The age at which a child exercises control over the act of defecation 
depends a great deal upon the training it receives. If no effort is made 
to form a habit, voluntary control of the bowels will in most cases be 
spontaneously established at about two years of age; but if, at the third 
or fourth month, the infant is placed upon the chamber each morning 
after feeding, the habit of having a stool at that time every day will 
have become fixed by the sixth month. Incontinence of feces, there- 
fore, should not be considered abnormal before the second year; but 
after this it is a pathological condition usually the result of an organic 
lesion elsewhere in the body, but occasionally functional or due to local 
irritation. 

Etiology. — Fecal incontinence is seen most frequently as the result 
of injury to the spinal cord, transverse myelitis, paraplegia, and coma- 
tose conditions; also in cases of severe asthenia with marked adynamic 
nervous state, such as occurs in typhoid fever, pneumonia, or cholera 
infantum, and in grave attacks of scarlet fever, diphtheria, or other 
acute infections. Except when found in association with the foregoing- 
conditions it is exceedingly rare, and may not be observed in the other- 
wise apparently healthy child, as is urinary incontinence. Sometimes 
incontinence of feces is associated with enuresis in extremely nervous 
children who show other signs of nervous instability, such as night 
terrors, stuttering, and habit spasms; occasionally there is fecal incon- 



DIARRHEA 331 

tinence without enuresis. Tli< v stools are abnormal, I >u t not neces- 
sarily diarrheal in character, since the bowels may be moved l>nt once 

daily, yet the movements have an offensive odor, are slimy, and some- 
times show fermentation. This condition is regarded as a nervous 
affection of the intestines, probably in some way related to the mucous 
colitis of adult life. 

Prognosis. — The prognosis is always good unless there is associated 
organic brain or cord lesion or mental deficiency. As a rule, the habit 
may be stopped within a week. When observed during the course 
of a severe acute illness it is merely a transient sign of asthenia, and 
disappears promptly with recovery from the primary disease. As in 
enuresis, relapses are common, and should be guarded against rigidly. 

Treatment. — The child with incontinence of feces should, first of 
all, be restricted as to diet, and all foods which have a laxative action 
on the bowels, such as fresh fruits and green vegetables, should be 
prohibited. In most cases a nerve tonic is needed, and excellent results 
may be obtained from the administration of one to three drops of tinc- 
ture of nux vomica or Fowler's solution, to which a nerve sedative, 
such as Dover's powder, 1 to 3 grains, or a combination of tincture 
of belladonna and sodium bromide should be added to relieve the 
excessive nervous irritability. Bismuth subnitrate in from 2- to 10- 
grain doses, according to the age of the child, should be given every 
three hours for one or two days if the bowels are loose. 

DIARRHEA. 

Diarrhea, one of the most common affections of infancy and child- 
hood, is said to exist when the stools become loose and watery, and are 
much increased in number. It is always a sign of some intestinal dis- 
order, since it is caused by increased peristalsis and increased intes- 
tinal secretion. Moreover, since diarrhea results in marked disturb- 
ance of digestion and nutrition, the diseases of infancy in which it is 
the most prominent symptom have by far the highest mortality. 

Etiology. — Diarrhea is, as a rule, observed in children from six 
months to two years of age, a fact largely accounted for by the liquid 
diet which they receive at this period of life. It does not occur in the 
breast-fed infant unless there is some disturbance of lactation, hence 
its comparative infrequency before the sixth month. But the fact that 
90 per cent, of cases of diarrhea are seen in bottle-fed infants seems 
almost proof positive that in improper feeding lies the chief cause. 
The error in diet may be either overfeeding, faulty composition of the 
formula, or contamination of the milk; here, again, the great prevalence 
of diarrhea in the summer time would seem to indicate that unsuitable 
or, more likely, spoilt milk, plays a large part in the diarrheas of infancy. 

In large cities the number of cases of diarrhea and the mortality vary 
each summer in direct proportion to the height of the temperature 
and duration of the hot spells, which shows also the effect of excessive 
heat in the production of this disease. Milk may also be unfit for use 



332 DISEASES OF THE GASTRO-INTESTINAL TRACT 

because of contamination by tilth from the stable, street, or store; 
hence the poorer classes furnish most of the cases of diarrhea which 
are due, in an indirect way, to unhygienic surroundings, poorly kept 
food, also to lack of fresh air, cleanliness, and sunshine. Fatalities 
from infantile diarrhea are far more numerous where there is a consti- 
tutional dyscrasia, such as tuberculosis, syphilis, rachitis, or malfor- 
formation, from any cause whatsoever. 

Classification. — There are tw T o main' groups of diarrheas: the simple, 
or non-infectious, and the infectious. Simple diarrhea may be clas- 
sified as follows: 

Mechanical. — That produced by indigestible articles of food which 
act as foreign bodies in the intestinal tract. In these cases the diarrhea 
is an indication of Nature's desire to rid the intestines of the irritating 
material, hence the best treatment is an initial purge to sweep out the 
offending substance, after which recovery is usually prompt. 

Medicinal. — In some infants the laxative effect of an ordinary 
cathartic will persist indefinitely. The milk of the mother, too, has 
a cathartic effect after she has taken certain purgatives. 

Eliminative. — Here diarrhea may be a demonstration of Nature's 
effort to rid the system of toxins by way of the bowel; for instance, 
eliminative diarrhea is seen in uremia, and occasionally in acute infec- 
tious diseases. 

Reflex. — Reflex diarrhea due to nervous shock, such as great fright, 
or excitement, is rather rare in children, but does occur, and is char- 
acterized by an excess of mucus in the stools. Occasionally diarrhea 
is brought on by chilling the surface of the body. 

Treatment of Diarrheas. — The first step in the treatment of a simple 
diarrhea is to ascertain the cause and remove it. In the majority of 
instances it is good therapy to give a full dose of castor oil, after which 
bismuth may be administered in fairly large doses, 5 to 10 grains, every 
two or three hours for a day or two. In the severe diarrhea of infancy 
it is well to stop all milk, and give nothing but water for 24 to 48 hours. 
In less severe cases barley-water, rice-water, egg albumen, or very weak 
broth may be substituted for the milk in order that the child should 
not suffer from utter lack of nourishment, and as soon as improvement 
sets in milk feeding should be resumed, beginning with very small 
quantities. 

INTESTINAL BACTERIA. 

At birth the intestines contain no bacteria, but shortly after nursing 
is begun the B. lactis aerogenes, B. coli communis, and putrefactive 
organisms may be found in the intestinal contents. The stool of a 
normal infant may reveal just as many organisms as that of the child 
who is ill ; but, for the most part, they are non-pathogenic, and practi- 
cally include all the bacteria found in the mouth. It is quite generally 
believed that the presence of certain bacteria in the intestinal tract is 
essential to good health, since if they are continually destroyed in the 
milk, the infant is liable to develop scurvy. The Bacillus acidophilus 



MUCOUS COLITIS 333 

is invariably to be found in the mouth and intestines, and the B. 
bifidus communis is often detected in the stools of breast-fed infants. 
Lactic acid is formed in the intestines by the action of the Bacillus 
lactis aerogenes, which depends for its growth upon milk sugar, and 
therefore invades the upper intestine, also by the action of the Bacillus 
coli, which lives upon intestinal secretions. In addition to these organ- 
isms, saprophytes, non-pathogenic cocci, the B. subtilis and, occasion- 
ally, the bacillus of Shiga, are found in the stools of normal infants, 
although the Shiga bacillus is the organism responsible for acute 
gastro-enteric infection in infancy. 

MUCOUS COLITIS. 

Mucous colitis, or mucous disease, is a chronic inflammation of the 
intestines characterized by intestinal indigestion and an excessive 
production of mucus, with the formation on the mucosa of a pseudo- 
membrane which is passed at intervals in the form of casts of the 
intestine and in ropy masses. The disease is essentially the same as 
that which occurs in the adult and, as a rule, the signs and symp- 
toms are similar. 

Etiology. — This disease is most common in delicate, neurotic children 
who are of neuropathic ancestry and precocious. It is very rare during 
infancy, usually occurring between the ages of five and twelve years. 
There may be a history of antecedent catarrhal colitis or of frequent 
attacks of intestinal indigestion. 

Symptoms. — Mucous colitis is apt to appear in recurrent attacks 
during which the child is acutely ill, complains of severe abdominal 
pain, and passes casts of the intestine and shreds of mucus in the stools. 
As a rule, there is constipation, with hard dry movements which are 
covered with mucus. Occasionally a stool is normal except that it 
contains large quantitites of mucus. The appetite is capricious, the 
tongue coated, the skin pale and anemic-looking. The child is irritable 
and peevish during the day and very restless at night; often it is under- 
nourished and loses weight. The attacks are brought on by indiscre- 
tions in diet or by nervous excitement such as that which fright and 
competitive games produce. 

Diagnosis. — The diagnosis is, as a rule, readily made upon finding 
mucous casts of the intestines and an excessive number of mucous 
shreds in the stools. The character of the stools will enable us to 
differentiate attacks of mucous colitis from the abdominal pain due to 
appendicitis; while a careful study of the signs and symptoms and 
consideration of the history will differentiate it from tuberculous 
peritonitis, which it occasionally resembles. 

Prognosis. — The outlook is favorable for final recovery; but the dis- 
ease runs a protracted course with frequent exacerbations and relapses. 

Treatment. — If necessary the bowels should be regulated by an even- 
ing dose of fluidextract of cascara sagrada, 20 to 30 drops. Enemata 
and colonic irrigations are contraindicated because of their tendency 



334 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

still further to irritate the colon, but a glycerin suppository may be 
used occasionally. 

Dietetic treatment is of the utmost importance, the progress of the 
case depending upon the careful and continued regulation of the diet, 
since each indiscretion is followed by a relapse. Carbohydrates are 
especially harmful in these cases, and all sugars and starches should 
be limited. Pastries, cakes, candies, potatoes, and bread must be pro- 
hibited or greatly restricted, and broths, stewed fruits, cereals, and 
meats substituted. Toast may be given in place of fresh bread. As 
a rule, milk is harmful. 

These children are anemic and below par, and they require tonic 
doses of tincture of nux vomica, one to three drops, or Fowler's solution, 
one to three drops, after meals. Improvement is much more rapid if 
a change of climate can be secured by sending the child to the sea- 
shore or mountains. 

AMYLOID DISEASE OF THE INTESTINES. 

Amyloid disease of the intestines is rare during infancy, but may be, 
seen occasionally in association with amyloid disease of the liver, 
spleen, or kidney. The exact metabolic changes which cause the depo- 
sition of lardaceous material is not understood, but the disease attacks 
children who are afflicted with syphilis, tuberculosis, or some chronic 
suppurative process. 

Pathology. — At the onset of the disease, a lardaceous substance is 
deposited in the walls of the small vessels of the intestinal villi, and is 
later found also in the mucosa and submucosa. 

Symptoms. — This disease gives rise to no definite or characteristic 
symptoms, and the diagnosis is made only at autopsy. 

Treatment.— There is no specific treatment for amyloid disease; 
but, in cases where it is suspected, the underlying cause should be 
ascertained, and removed if possible. 

INTESTINAL OBSTRUCTION. 

Obstruction of the intestines may be either congenital or acquired 
and, while the congenital form is the one usually met with during 
childhood, the acquired type is by no means uncommon. The affec- 
tion when acquired is the result of intussusception, strangulated hernia, 
volvulus, impaction of a foreign body in the intestine, peritonitis, 
constricting bands, or the pressure of intra-abdominal tumors. The 
congenital form is due to malformation of the intestinal tract, hernia 
of the umbilical cord, imperforate anus or rectum, or other anatomical 
anomaly. 

Symptoms. — The symptoms of complete obstruction of the bowels 
are vomiting and the passage of a small amount of feces mixed with 
blood and mucus, after which there is absolutely no movement of 
the bowels. Vomiting persists, and becomes stercoraceous if the 



APPENDICITIS 335 

obstruction is not relieved, while pain is severe and paroxysmal. 
The pulse soon becomes weak, exhaustion and prostration ensue, 
and sepsis quickly supervenes from the absorption of toxins. The 
temperature is high; the abdomen is distended and tympanitic. 
If the obstruction is not relieved the gut now becomes gangrenous, 
pain ceases, sepsis is profound, and the child dies in collapse within 
twenty-four hours from the time gangrene sets in. 

Diagnosis. — The diagnosis is based upon the history of absolute 
constipation, persistent vomiting which becomes stercoraceous, and 
symptoms of collapse with severe abdominal pain, together with other 
symptoms which vary according to the nature of the obstruction. 

Prognosis. — The prognosis of intestinal obstruction is at the best 
unfavorable. The chances of recovery are greatest in those cases 
in which the diagnosis is made early. After gangrene has set in death 
is almost a certainty. 

Treatment. — The treatment is wholly surgical, and consists in 
abdominal section and removal of the obstruction. If a portion of 
the gut is gangrenous, resection is also necessary. 

VOLVULUS. 

Volvulus is a twisting of the bowel upon itself in such a way that 
its lumen is occluded and obstruction is the result. The onset is 
sudden, and is marked by severe pain followed by absolute stoppage 
of the bowels. The abdomen is distended and extremely tender, 
but there is rarely stercoraceous vomiting. It is impossible to find 
a tumor either by abdominal palpation or rectal examination. The 
symptoms rapidly become aggravated, but collapse does not appear 
as quickly as in other forms of bowel obstruction. This condition is 
very rare in children; when it occurs the sigmoid is most frequently 
the portion of bowel involved, and the treatment is surgical. 

APPENDICITIS. 

This affection is of much less frequent occurrence in children than 
in adults, and is extremely rare during infancy. The majority of 
cases are observed in children between five and fifteen years of age. 
The acute form is the more common and, as a rule, an attack of 
appendicitis runs a much more rapid course in children than in adults. 
Chronic appendicitis is very infrequent during childhood. In many 
respects the disease presents quite a different aspect in the child, the 
symptoms being more obscure, and the appendix lying farther above 
the pelvic brim than in the adult, which makes the seat of tenderness 
and pain above McBurney's point. The treatment also differs to a 
certain extent from that in the adult. 

Etiology. — Appendicitis is more common in boys than in girls, and 
becomes more frequent as the child advances from infancy. Its rarity 
in children before the second year is due to the infant's liquid diet 



336 DISEASES OF THE GASTRO-INTESTINAL TRACT 

and the relatively wider lumen of the appendix at this age. Heredity 
may be considered a predisposing cause when a tendency to constipa- 
tion is inherited or when certain anomalies of the appendix are observed 
in successive generations of a family. Fecal concretions which 
block the lumen of the appendix are the cause of most of the acute 
attacks, but obstruction of the appendix is rarely due to a foreign 
body. 

In many instances there is a history of digestive disturbance and 
constipation; but these conditions may be regarded merely as pre- 
disposing factors, since bacteria are the exciting cause in every case. 
An extension of intestinal inflammation into the appendix may pro- 
duce appendicitis; but this is infrequent, and only in exceptional 
cases do we elicit a history of preceding injury to the abdomen or 
of intestinal parasites. The affection is occasionally associated with 
acute infectious diseases, such as scarlet fever, follicular tonsillitis, 
and typhoid fever. 

Pathology. — The same forms of acute appendicitis are observed 
in children as in the adult — the catarrhal, suppurative, perforative, 
and gangrenous. Ulceration or perforation is quite common, and 
increases the gravity of appendicitis in children. Catarrhal appen- 
dicitis is characterized by swelling and rigidity of the appendix, hyper- 
emia of the mucous membrane, and infiltration of the walls with 
round cells. The lumen of the appendix is almost obliterated, and 
usually contains fecal concretions and mucus or mucopus. 

In inflammation of the appendix in children there is a marked 
tendency to pus formation and, as a consequence, the catarrhal type 
is usually followed by suppuration. In a few instances recovery 
ensues without pus formation, while more rarely chronic catarrhal 
inflammation may follow. In suppurative appendicitis the inflam- 
mation of the appendix is more severe owing to the deficient blood 
supply and more virulent infection; all the coats of the organ are 
involved, and its lumen is filled with pus. In acute appendicitis in 
children the tendency is toward abscess formation; but, although 
perforation is not infrequent, peritonitis is rare, for the abscess is 
usually walled off by adherent omentum. 

Gangrenous appendicitis is the result of an obstruction to the 
circulation in the appendix which causes the tip to become necrotic. 
As in the perforating form, the contents of the appendix are discharged 
through the opening thus made, and this sets up a localized or general 
peritonitis according to whether or not there are inflammatory adhe- 
sions to limit the spread of infection. 

Localized gangrene of the appendiceal wall from pressure of a 
large fecal concretion is the usual cause of perforation of the appendix; 
but in these cases peritonitis does not assume the grave septic aspect 
commonly observed in gangrenous appendicitis. Intestinal obstruc- 
tion following acute appendicitis, and due to strangulation of the gut 
and inflammatory adhesions about the appendix, while comparatively 
rare, occurs with greater frequency in children than in adults. Chronic 



APPENDICITIS 337 

appendicitis, although seldom seen in children, may be the sequel to 
several acute catarrhal inflammations. At autopsy the appendix 
is found to be thickened, tortuous, and bound down by adhesions to 
the adjacent tissues. 

Bacteriology. — While inflammation of the appendix can be attributed 
to no special organism, yet in the majority of cases in which bac- 
teriological studies have been made the colon bacillus has been found 
in large numbers. Among the other organisms isolated are typhoid 
and tubercle bacilli, and the streptococcus and staphylococcus. 

Associated Lesions. — x\ppendicitis, especially the acute suppurative 
form with abscess formation, is occasionally the cause of suppuration 
in other organs. This tendency to secondary abscess is more marked 
in children than in adults. Not infrequently an abscess may be dis- 
covered in the liver, brain, parotid gland, lung, or in tissues adjacent 
to the appendix. 

Symptoms. — Mild catarrhal appendicitis often escapes recognition 
in children, owing to the fact that the symptoms are not unlike those 
of acute gastric or intestinal indigestion. There are pain and tender- 
ness in the abdomen, but these are rarely referable to the right iliac 
fossa; and, unless appendicitis be suspected and an attempt made 
to elicit tenderness over the appendiceal region, no local symptoms 
may be apparent. 

The onset of such an attack is sudden; it may or may not be preceded 
by gastro-intestinal disturbance as manifested by anorexia, general 
malaise, and either constipation or diarrhea. Vomiting is rather a 
constant feature, often persisting until the attack subsides. There 
is usually a hypersensitive state of the bladder with frequent and, 
sometimes, painful micturition, and by rectal examination of the 
cecal region we can often detect inflammation of these parts. 

Rigidity of the abdomen is not so valuable a diagnostic sign in 
children as in adults, since, even though there be neither pain nor 
tenderness, the child may resist all efforts to palpate the abdomen. 
If the inflammation is but slight, the temperature does not ascend 
above 101° or 102° F., and in the course of three or four days sub- 
sides. There is, however, greater elevation of temperature in children 
than in adults, the height always depending upon the severity of the 
attack except when gangrene or perforation has caused the tempera- 
ture to fall. 

In a severe attack of acute catarrhal appendicitis the symptoms are 
much more pronounced and the disease more clearly defined. The 
fever may rise above 105° F.; the pulse is rapid; vomiting and pain 
are severe. There is distinct tenderness over the appendiceal region, 
which in children is a little above McBurney's point, and the right 
rectus muscle is rigid. If the abdomen .be examined before rigidity 
appears, it may be possible to palpate the firm, swollen appendix by 
making pressure on the back opposite to McBurney's point with the 
left hand while palpating deeply in the region of the appendix and down 
into the pelvis with the fingers of the right hand. 
22 



338 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

In ulcerative or perforative appendicitis the symptoms at the onset 
are those of a severe form of acute catarrhal inflammation. The 
attack comes on suddenly with vomiting, constipation, fever of 102° 
to 105° F., and severe abdominal pain. At first the increase in the 
pulse rate corresponds with the elevation of temperature; but after 
perforation the temperature usually falls, while the pulse becomes 
more rapid and thready. 

If the appendix is well walled off by the omentum and inflammatory 
adhesions, perforation causes merely a localized peritonitis which is 
indicated by an area of induration about McBurney's point. When 
suppuration takes place an abscess forms, and the patient suffers from 
chills and sweats. At this stage the child usually assumes a charac- 
teristic posture; it lies on its back with the knees drawn up, and the 
abdomen held quite rigid. The pulse is rapid, the tongue coated; 
vomiting continues; the face wears an anxious, pinched expression. 

If an abscess forms, a tumor-like mass may be felt in the right iliac 
fossa and the whole abdomen be distended; but fluctuation is difficult 
to make out because of the depth of- the suppurative process. Its 
location depends, however, upon the situation of the appendix. If 
the organ lies in the pelvis, the abscess is often readily perceptible 
upon rectal examination. 

Few cases are allowed to proceed beyond this stage without opera- 
tion; but until the abscess is opened it continues to increase in size, 
pain and tenderness persist, the child stoops or limps if placed upon 
its feet, and the temperature remains elevated. As a rule, fluctuation 
is easily detected. The abscess either ruptures externally through 
the skin or empties its contents into the general peritoneal cavity, 
and thus gives rise to peritonitis. In rare instances the pus is evacu- 
ated into the rectum, bladder, or vagina, and peritonitis does not 
occur. 

Gangrenous appendicitis, while most severe, is not accompanied by 
any characteristic symptoms, and the course of an attack is so decep- 
tive that the mortality is very high. This is because the child's 
exact condition is not recognized, and the decrease in pain and tender- 
ness, and decline of the fever which accompanies gangrene of the 
appendix, are mistaken for signs of recovery, whereupon operation is 
postponed, and septic peritonitis develops a day or two later. 

The shock from rupture of a gangrenous appendix is profound, and 
is usually attended by vomiting, acute pain, and collapse, while 
ordinary perforation or ulceration of the appendix causes sharp pain, 
a fall in temperature, and accelerated pulse rate. 

General peritonitis — which follows perforation or gangrene of the 
appendix when the appendiceal region is not walled off — is marked 
by a rise of temperature, weak, thready pulse, rapid and shallow 
respirations, cold and clammy skin, and often persistent hiccoughs. 
The face wears an anxious expression; nausea and vomiting continue. 
The child is constipated. The abdomen is distended and tympanitic, 
and there is a board-like rigidity of all the muscles of the abdominal 



APPENDICITIS 

wall. General peritonitis is most common in gangrenous appendicitis, 
the disease being so acute that there is usually insufficient time for 
the walling off of the appendix; consequently, when it ruptures the 
contents escape into the peritoneal cavity. Recovery from general 
peritonitis is rare, especially from the form which follows gangrene 
of the appendix, this being usually of extremely septic type. 

Chronic Appendicitis. — The symptoms of chronic appendicitis arc 
much milder than those of the acute form. There is a history of one 
or more acute attacks, followed by more or less complete recovery; 
but the child constantly complains of pain and discomfort in the 
appendiceal region. There may be slight fever at intervals, and occa- 
sionally an attack of appendiceal colic with vomiting and constipation. 
These children, while, perhaps, not as healthy as the normal child, 
do not show the nervous effects of chronic appendicitis which arc so 
frequently observed in adults who suffer from this disease; and, as 
a rule, there is little emaciation or debility. 

Diagnosis. — The all-important aid to the diagnosis of appendicitis 
in children is rigidity of the abdominal wall, especially on the right 
side, together with accompanying localized symptoms, such as pain 
and tenderness in the right iliac fossa. In the absence of these indi- 
cations of appendiceal inflammation the diagnosis is very difficult, 
and may be impossible, since all of the additional signs and symptoms 
are those which may also be found in other gastro-intestinal affections. 
If the appendix lies in an anomalous position, appendicitis is rarely 
thought of, and may altogether escape recognition unless an explora- 
tory operation be performed. 

It is highly important that appendicitis be recognized early; at 
the same time, because of its similarity to many other diseases of 
the gastro-intestinal tract, careful differentiation is often necessary. 
Intestinal colic may be ruled out by the absence of fever and localized 
tenderness, also by the tendency of the symptoms to subside within 
a short time. In bowel obstruction there is neither tenderness nor 
pain in the right iliac fossa. In intussusception the tumor can usually 
be palpated in the centre of the abdomen or on the left side, and may 
often be detected by rectal examination. The stools contain blood 
and mucus; there is no fever at the onset; constipation becomes 
absolute. Intussusception is also rare after infancy, while volvulus 
is so extremely rare in children that it needs no consideration. 

For a day or so it may be impossible to exclude acute indigestion, 
enterocolitis, and colic with fever; but, after the lapse of twenty- 
four hours, colic and acute indigestion usually show marked improve- 
ment with cessation of the pain or localized tenderness in the right 
iliac fossa, while in enterocolitis the constant diarrhea with mucous 
stools discloses the nature of the affection. 

Right-sided pneumonia, especially when accompanied by diaphrag- 
matic pleurisy, may produce signs closely simulating acute appen- 
dicitis. The right rectus muscle may be rigid, and, until physical 
signs appear in the lungs, a diagnosis is frequently impossible. Rapid 



340 DISEASES OF THE GASTRO-INTESTINAL TRACT 

respiratory rate, limited motion of the right chest, and negative rectal 
examination of the cecal region may all favor pneumonia. The leuko- 
cyte count, while not of great service in differentiating appendicitis 
from pneumonia, is a valuable adjunct in the exclusion of gastro- 
intestinal disturbances, such as acute indigestion, colic, ileocolitis, 
and intussusception. 

To a certain extent one can also differentiate acute catarrhal inflam- 
mation from suppurative appendicitis; but it is by no means always 
possible. As a rule, a count of 12,000 or less usually signifies catarrhal 
inflammation, while a leukocytosis of 20,000 or over indicates suppura- 
tion. It must also be borne in mind that in severe acute cases there 
may be no leukocytosis. In order to obtain the most accurate data 
from a blood examination in appendicitis, a series of counts should 
be made, since a rising leukocytosis is far more significant than a 
single high count. 

Prognosis. — When an early diagnosis is made, and the case is operated 
upon immediately, the prognosis is favorable. In mild cases of acute 
catarrhal appendicitis the outlook is, as a rule, also favorable; but 
suppuration and abscess formation are more common than in adults. 
Cases of appendicitis which are operated upon late, and those occur- 
ring in children under five years of age, are alike more unfavorable as 
to outcome. 

Treatment. — Rest in bed is imperative. During the early stages of 
inflammation, an ice-bag should be kept over the appendiceal region. 
Nothing should be given by mouth but water or albumen-water. If 
pain be severe, and an operation is to be performed, opiates may be 
given in small doses — J to J grain Dover's powder. But in those 
cases which the physician must treat expectantly, either because the 
diagnosis is not clearly established or operation is refused, opiates are 
contra-indicated, since they mask important symptoms. 

An enema may be given to open the bowels; in some cases it is 
well to place the child in a sitting posture with the knees flexed, as 
suggested by Fowler, and give salt solution by slow proctoclysis. 
When the diagnosis is positive, surgical interference should be urged, 
and no further attempt need be made to treat the case medicinally. 
If operation is refused, the child should stay in bed on a liquid diet, 
and the bowels be kept moving daily by the use of enemata. 

These cases must be closely watched. If the fever continues and 
no improvement is noted, operation is demanded. Any sign of per- 
foration or gangrene, as shown by a drop in the temperature with 
accelerated pulse rate and evidences of shock, calls for immediate 
operation. If, on the other hand, there is improvement under medi- 
cinal treatment, the case may be allowed to proceed to recovery. 
An interval operation should, however, be advised, since one attack 
of appendicitis is usually succeeded by others until the appendix is 
removed. 

The treatment of chronic appendicitis is surgical. An appendectomy 
should be performed in the interim between acute exacerbations. In 



INTESTINAL WORMS 341 

treating appendicitis in children the medical man should always 
secure the assistance of a surgeon. Owing to the tendency to abscess 
formation, operation is the wisest procedure in every case. 

INTESTINAL WORMS. 

Children are nowadays much less frequently infested with worms 
than they were a generation or so ago, and it is today the consensus 
of opinion that the injurious effects of intestinal parasites have been 
greatly overestimated. The same varieties are found in children as 
in adults; but in the majority of children the parasites present are 
the threadworm and the roundworm. 

Etiology. — Children of the poorer classes are the usual hosts of these 
parasites, the disease being seen less commonly in private practice. 
Infants seldom harbor worms, for the reason that parasite's gain 
entrance to the body through the ova which are swallowed with food 
and water, or are carried to the mouth by means of the fingers, or are 
on articles picked up off the floor or street by young children. 

Symptoms. — The general symptoms produced by intestinal worms 
are indefinite and vague. Anemia, loss of weight, diminished appetite, 
and peevishness may be the only signs that the child is ailing; but in 
severe cases we find vomiting, colic, restlessness and moaning at 
night, a constant desire to pick at the nose, gritting of the teeth, and 
more or less nervousness, sometimes even convulsions. 

When the body is infested by intestinal parasites there is always 
secondary anemia; but, in addition, there are other and more 
characteristic changes. Eosinophilia usually accompanies all forms 
of intestinal infestation, but is most marked when trichinae are present. 
In trichiniasis also there is usually leukocytosis. Severe secondary 
anemia as a result of intestinal parasites may exhibit a blood picture 
not unlike that of pernicious anemia. Aside from these general con- 
stitutional symptoms caused by animal parasites, there are other 
signs and symptoms which vary more or less according to the particular 
type of worm present. 

Cestodes. — The Taenia mediocanellata, or beef tapeworm, and the 
Taenia solium, or pork tapeworm, are the most common varieties. 
The Bothriocephalus latus, or fish tapeworm, and the Taenia cucume- 
rina, the Taenia nana, and the Taenia echinococcus are quite rare. 
Among the nematodes, the Oxyuris vermicularis, or threadworm, the 
whipworm, and the Ascaris lumbricoides, or roundworm, are the most 
common forms found in children. The hookworm, or Ankylostoma 
duodenale, or Uncinaria duodenalis, while quite common in the South, 
is rarely seen in the northern part of the United States. Trichinae 
seldom infest children, since the ova are ingested by eating uncooked 
pork. 

Taeniae, or Tapeworms. — Tapeworms are matured or fully de- 
veloped larvae from the muscles and solid viscera of animals. The 
ova are taken into the bodies of various animals, and carried to the 



342 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

solid tissues, especially to the muscles, where they lodge, and in two 
or three months they produce cysts the size of a pea within which 
there forms a taenia head or scolex. If the flesh containing these cysts 
is eaten uncooked, a tapeworm will develop from the scolex, and the 
segments of the tapeworm will mature several months after the 
fixation of the scolex in the intestine. When mature, the segments 
develop male and female generative organs. 

Taenia Solium, or Pork Tapeworm. — The pork tapeworm is less 
common than the Taenia mediocanellata, or beef tapeworm. It develops 
in the small intestine after the ingestion of raw or underdone measly 
pork. Usually there is but one worm in the intestine, but there may 
be more than one. The Taenia solium ranges from six to thirteen feet 
in length. Its head is rounded, of pin-head size, and is succeeded by 
a thread-like neck, then by segments which gradually become shorter 
and broader. There are four suckers and a projecting circle of twenty- 
six long and short booklets about the head of the taenia. 

The segments, when mature, become detached and are passed out 
of the intestine with the feces. They are a little less than a half-inch 
in length and one-quarter of an inch in breadth, but vary so much 
in shape that at about three feet from the head they are quadrilateral. 
The female matrix occupies the middle of each segment, and is pro- 
vided with eight to fourteen tree-like branches on each side. The 
male generative organs are small vesicles in the anterior portion of 
the segment. The sexual opening is on one side near the middle. 
The ovarian or uterine apparatus of a mature segment contains many 
thick-shelled eggs, each of which holds within it an embryo with six 
hooklets. 

Taenia Mediocanellata, or Beef Tapeworm. — The beef tapeworm is 
the most common variety met with in the human being. It varies 
from 12 to 30 feet in length. In comparison with the Taenia solium, or 
pork tapeworm, its segments are thicker and broader, being approxi- 
mately f of an inch long and half as broad. The head of the worm is 
larger and thicker, and contains sucking disks, but no hooklets. The 
ova are larger, and the ovarian branches of the female matrix are more 
numerous. 

Bothriocephalus Latus, or Fish Tapeworm. — This variety of tape- 
worm is found most commonly in foreign countries. It is longer than 
any other intestinal parasite, measuring 20 to 30 feet. The head is 
unarmed and club-shaped; it has two longitudinal suckers. The seg- 
ments are broader than those of the other varieties of tapeworm, and 
the ovarian apparatus is rosette-shaped and situated in the centre. 
The ova are larger than those of the beef or pork tapeworm, and have 
a lid at one end. They develop only in fresh water, and here they 
form an embryo which is eaten by fish, These embryos form cysts in 
the viscera and muscles of the fish, and if the fish are eaten raw or 
only partially cooked scolices develop in the intestine. 

Dwarf Tapeworm — Taenia Nana. — This tapeworm is the smallest 
variety found in man, measuring from f to 1 inch in length, and -^q 



IXTEST1MAL WORMS 343 

of an inch in width. The head has four suckers, a rostellum, and 
hooklets. The segments are yellowish, short, and broad. Taenia 
nana is more common in children than is generally supposed. 

Symptoms. — The subjective symptoms of tapeworm are vague and 
indefinite, and are directly due to the irritation produced by the 
worm within the intestine. There is always a certain amount of 
gastro-intestinal disturbance, which is often very slight, but in some 
cases may cause diarrhea, colicky pains in the abdomen, and either a 
capricious appetite or anorexia. The breath is foul; at intervals there 
may be nausea and vomiting. None of these symptoms, however, is 
at all characteristic of intestinal worms any more than it is pathog- 
nomonic of other derangements of digestion. 

These children are usually irritable and peevish during the day 
and extremely restless at night from nervous excitation; but the 
symptoms referable to the nervous system are not as severe as those 
caused by the roundworm, and convulsions are rarely seen. In many 
cases the child may be apparently in good health; but there is usually 
a gradual loss in weight, accompanied by anemia which may reach 
an extreme degree, but is usually slight and of secondary nature. 
Eosinophils is also a common finding on blood examination. 

Diagnosis. — The diagnosis of tapeworm can be made only when the 
segments appear in the stools, and when their presence in the intestine 
is suspected a purge should be given to bring about their expulsion. 
Since the treatment for the different varieties of tapeworm differs 
slightly, the segments and the head should be examined microscopically 
in order to identify the particular type of worm present. If no seg- 
ments are passed, the feces should be examined microscopically for 
the ova, which are quite numerous and easily found if a tapeworm 
inhabits the intestinal tract. 

Prognosis. — It is seldom a difficult matter to expel a tapeworm, and 
since its presence causes no severe symptoms the outlook is in most 
cases very good. The only possible danger to life arises when the 
eggs of the pork tapeworm find their way into the stomach. When 
this occurs the embryos are formed in the intestinal canal and may 
pass through the intestinal wall, and become lodged in the muscles, 
the viscera, or even in the brain. 

Treatment. — Prophylaxis is important, and consists for the most 
part in prohibiting for the use of the child any beef or pork which has 
not been inspected. This is especially imperative in those cases where 
rare beef or beef juice is being given to children, and here the mother 
should personally inspect the meat for cysticerci before she prepares 
it for the child. These cysticerci will look like small cysts the size of 
a pea in the beef. When practicable, the safest and surest precaution 
against tapeworm is thoroughly to cook all meat and fish, as this abso- 
lutely destroys the cysticerci. 

Fecal discharges from children who harbor tapeworms should be 
carefully disinfected with 5 per cent, carbolic acid solution before 
being disposed of, to prevent infection from being transmitted to other 



344 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

children or to animals by the ova which they contain. Care is also 
necessary to keep the child from reinfecting itself by its soiled hands 
or by the receptacle into which the stools are passed. 

The most widely used drug for the expulsion of the tapeworm is 
aspidium, or male fern (filix mas), which should be given in doses of 
5 to 30 drops, according to the age of the child. Both this and other 
drugs used for the expulsion of the tapeworm cause more or less irri- 
tation of the gastro-intestinal tract; therefore, it is advisable to use 
as little as possible, and in order to facilitate the action of the vermifuge 
the following plan of treatment is usually resorted to : 

The night before the vermifuge is to be taken, the child is given a 
very light supper, and then a full dose of castor oil, | to 1 ounce. 
Another dose of castor oil is administered before a very light breakfast 
the next morning. Then the aspidium is given, preferably in divided 
doses three hours apart until the proper amount has been taken, when 
another dose of castor oil is administered. 

The stools are carefully examined for the head and segments of the 
worm. If the segments continue to come away or the symptoms 
persist, it may be necessary to repeat this treatment over and over 
until the head is found in the stool; for, unless it is passed, the worm 
will grow again. One or, at the most, two treatments will usually bring 
away the head. 

While the child is being treated for tapeworm special attention 
should be paid to its diet, which should be as light as possible to aug- 
ment the action of the vermifuge, and also to lessen the danger of 
gastro-intestinal disturbances from its irritating effect. 

Other drugs used to expel tapeworms are pelletierin, dose 1 to 2 
grains, infusion of pepo or pumpkin seeds, dose 1 dram, and an emul- 
sion of turpentine containing 10 drops of turpentine to the dram. 
The latter is given in teaspoonful doses every three hours for a day or 
two, being preceded and followed by castor oil, or the turpentine may 
be given in 1-dram doses combined with an ounce of castor oil. 
An infusion of kooso or brayera may be made by adding a half-ounce 
of powdered leaves to a pint of water and of acacia in equal parts. 
From 2 to 8 ounces of this may be given, according to the age of the 
child, and should be followed by castor oil. Thymol in 5- to 30-grain 
doses has also been found efficacious. 

Nematodes. 

This variety of worms is much moie common in children than the 
cestodes. More than one worm is usually present at a time, but they 
do not attain the size of the cestodes. Among the most common 
nematodes found in children are the round worm, threadworm, whip- 
worm, trichina, and hookworm. 

Oxyuris Vermicularis — Threadworm. — This is a very small worm, 
also called the pin- or seatworm, which inhabits the colon, and espe- 
cially the rectum. It forms in such great numbers that large masses 



INTESTINAL WORMS 345 

composed of the worms may be passed by the bowel. They are quite 
commonly found in children, but may also infest adults. The female 
worm is white in color, and about half an inch long, while the male 
is but | of an inch in length. They develop from ova in about two 
weeks after the ingestion of the eggs, which are of an irregular ovoid 
shape, and 5-^ of an inch in length. 

By the time the embryos reach the cecum they are sexually mature, 
and when the female arrives in the rectum she deposits there immense 
numbers of eggs that mature into myriads of worms which are dis- 
charged with the feces. Infection with the ova may take place by 
means of water or food, and also through the uncleanliness of persons 
infested. Scratching about the anus results in contamination of the 
hands which soil anything they touch, and thus spread the infection. 

Symptoms. — Itching and irritation about the anus and genitalia 
are the most characteristic symptoms of threadworms. The irritation 
of the colon may also cause a constant discharge of mucus from the 
rectum. The child suffers most from the itching in the evening, for 
at this time the worms migrate and get into the folds of the rectum. 
During the day the child is very restless, and constantly scratches the 
buttocks. 

Incontinence of urine is occasionally due to threadworms, and 
frequent micturition is a common symptom. As with roundworms, 
picking at the nose and grinding the teeth are rather characteristic, 
and indicate disturbance of the nervous system; while anemia, loss 
of appetite, and loss of weight show the effects of threadworms upon 
the general health of the child. 

Sometimes there is an accompanying catarrhal colitis, and vulvo- 
vaginitis or balanitis may also be attributed to threadworms because 
the itching produced so easily leads to the habit of masturbation. 
Severe consequences from threadworms are rare; but appendicitis 
has been traced to an accumulation of these parasites in the intestine, 
and convulsions occasionally supervene. 

Diagnosis. — Obstinate pruritus in children should make the physician 
suspect the presence of threadworms as a causative factor, and the 
stools should be examined for ova. A positive diagnosis is, however, 
impossible until either the worms or their ova are fomid in the feces. 

Prognosis. — In the majority of cases, all of the worms may be swept 
out of the intestine in a short time by proper treatment; but, occa- 
sionally, it is difficult to rid the child of the parasites, either because 
they are in the cecum where injections do not reach them or because 
the child is allowed to become contaminated and continuously rein- 
fected via the mouth. 

Treatment. — When the worms are all in the lower part of the colon, 
enemata will often suffice for their removal. The lower bowel should 
first be irrigated with warm salt solution to wash out all of the feces 
and mucus, and then an infusion of quassia or garlic, or a 1 to 10,000 
solution of bichloride of mercury, should be injected, 6 or 8 ounces 
being allowed to remain within the bowel for an hour. In order to 



346 DISEASES OP THE GASTR0-1NTESTINAL TRACT 

clean out the colon effectually a long rectal tube should be used for 
the injection. 

But the threadworms are often lodged so far up in the bowel that 
this treatment is unsuccessful, therefore santonin and calomel, of 
each J to J a grain, or the fluid extract of quassia, 10 to 20 drops, 
should be given prior to the irrigation, and in addition a purge of 
castor oil, 2 drams to an ounce, or magnesium sulphate, 1 dram to 
half an ounce, to drive the parasites into the lower bowel. It is advis- 
able to repeat the saline irrigation and the injections every evening 
for a week, by which time most children will have been cured. 

In many instances examination of the stools will fail to reveal either 
ova or worms after the second or third injection; but when they have 
lodged in the cecum and also inhabit the small intestine, a much 
longer course of treatment is frequently necessary. 

Treatment, while beneficial, may not wholly rid the child of thread- 
worms because of the ease- with which reinfection takes place. This 
is usually due to the transmission of the ova from the contaminated 
clothing and buttocks to the mouth by means of the hands, and espe- 
cially the finger nails, beneath which the ova lodge when the child 
scratches. For this reason the buttocks should be carefully cleansed 
and bathed with a.l to 10,000 bichloride solution after each bowel 
movement, and the itching should be controlled by anointing the 
anus with a dilute mercurial ointment at night and after each stool. 
All underclothing, diapers, nightgowns, and bed linen should be 
thoroughly boiled as well as cleansed when soiled. 

The stools should be treated with 5 per cent, carbolic acid solution 
before being disposed of, and the receptacle they are passed in disin- 
fected. The child, if old enough, must be taught to keep the hands 
clean by washing them whenever they have come in contact with the 
buttocks, and the finger nails should be scrubbed with soap and water 
to dislodge the ova. At night scratching may be prevented by sewing 
up the sleeves of the sleeping garment. 

If the general health of these children has been affected, they 
should be put upon a nourishing but light diet, encouraged to play 
out of doors, and given a tonic containing tincture of gentian or quas- 
sia which will serve the double purpose of building up the system and, 
to a certain extent, acting as a vermifuge. 

Ascaris Lumbricoides— Roundworm. — The roundworm occurs more 
frequently in children than any other intestinal parasite, par- 
ticularly in children between the ages of three and ten years. It 
inhabits the upper portion of the small intestine. In appearance it 
is very much like the common earthworm, its body being round, 
fusiform, and of a reddish-brown color. The female is 7 to 14 inches 
long, while the male measures from 4 to 8 inches. It is about as thick 
as a goose quill, and the head is furnished with three oval papilla? 
which have fine teeth. 

The ova are elliptical in shape, of a dark reddish color, and about 
0.05 mm. long. They are, in all likelihood, ingested with water and 



1NTESTIXAL WO It US 347 

food. At times these worms migrate from the small intestine, having 

been found even in the pharynx, mouth, nares, larynx, and trachea, 
and have caused asphyxia, pulmonary gangrene, and hepatic abscess. 

Symptoms. — A child may harbor a number of roundworms in the 
intestine without showing any sign whatsoever of their presence. 
Intestinal irritation may give rise to digestive disturbances with colic, 
tympanites, constipation or diarrhea, and loss of appetite, or even 
nausea or vomiting. These children are usually very restless at night 
and peevish during the day, with a tendency to pick at the nose 
continually and to grind the teeth. 

Evidence of rectal irritation may also be noticed, but is not charac- 
teristic, while headache is not uncommon. Nervous symptoms are 
usually mild; but occasionally round worms may cause dizziness, 
hysteria, syncope, or convulsions. The harmful effects of roundworms 
on the nervous system are supposed to be due to the absorption of 
poisons which they excrete into the intestinal canal. Eosinophilia 
is a common finding. 

Diagnosis. — It is scarcely possible to make a diagnosis of round- 
worm infestation upon the symptoms enumerated above; therefore, 
unless their presence is suspected and the stools are examined for ova, 
the diagnosis is not made until a worm is passed in the stool, and 
discovered by the child or its parent. The stools of children who har- 
bor roundworms always contain a multitude of ova which are easily 
detected by microscopic examination. As a rule, several worms are 
present in the intestinal tract at one time; hence the persistence of 
the symptoms after the passage of one or more worms indicates that 
there are still others in the bowel. 

Treatment. — The best drug for expelling roundworms is santonin. 
The child should be given a light supper and a half-ounce to one ounce 
of castor oil befoie going to bed. The following morning santonin 
should be given, combined preferably with calomel. A child one 
year old should take a half-grain three times during the day with the 
same quantity of calomel. This dose may be doubled for children 
over three years old. The last dose of santonin is given in the evening, 
and the next morning from 1 to 3 drams of magnesium sulphate should 
be administered before breakfast. 

If more worms are passed after this treatment it must be repeated 
until they are no longer seen in the stools and microscopic examination 
of the feces shows the absence of ova. Other vermifuges which may 
be used are fluidextract of spigelia, dose \ to 1 dram, and senna. To 
prevent the child from reinfecting itself the hands and anus must be 
kept perfectly clean and as free from ova as possible. The expulsion 
of all the worms is usually followed by a cessation of the symptoms, 
after which no further treatment is necessary unless the child has 
become anemic, when an iron tonic should be prescribed. 

Trichocephalus Dispar. — The Trichocephalus dispar, or whipworm, 
frequently accompanies threadworms when they infest the colon, 
but its presence is rarely discovered. This parasite closely resembles 



348 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

the threadworm. The male measures 3 to 4 cm. in length, while the 
female is somewhat longer and sometimes attains a length of 5 cm., 
or 2 inches. The tail end of the female is conical and pointed, while 
that of the male is blunt and coiled up like a spring. The rest of the 
worm up to the head is slender and hair-like. The head is very small, 
but has the power of attaching itself most firmly to the intestinal wall. 

The ova are but 0.05 mm. (0.0012 of an inch) long, and have a 
button-like projection at one end. In most instances this parasite 
lodges in the cecum, although it may also inhabit the small intestine 
and the appendix. It is very rarely found in infants; but of all the 
parasites that infest man the trichocephalus is said to be more common 
during childhood and adult life than any other. It is supposed to 
gain entrance to the intestine by the ingestion of the ova in drinking 
water. 

Symptoms. — As a rule, only a few worms are in the intestine at one 
time, therefore the symptoms are few and very slight; but when a 
large number of these parasites collect in the cecum the consequences 
may be serious. In such cases anemia is quite marked, and even 
brain symptoms have been attributed to the whipworm. On account 
of the usual association of the threadworm with the whipworm, the 
threadworm being present in far greater numbers, it seems reasonable 
to suppose that these symptoms are only in part due to the Tricho- 
cephalus dispar. 

Diagnosis. — The presence of this parasite is rarely diagnosed during 
life, although the ova may be found in the stools and identified under 
the microscope. 

Treatment. — In order to prevent the whipworm from effecting 
entrance to the intestine, precautions should be taken to ascertain 
the purity of all drinking water. Salt solution and infusion of garlic 
or quassia, or a solution of 1 to 10,000 bichloride of mercury, should 
be used as injections in the manner described in the treatment of 
threadworms; but it is usually necessary to supplement these meas- 
ures by the oral administration of drugs because of the habitat of the 
whipworm, which is too high in the colon to be effectively reached 
by rectal irrigation alone. Calomel, 1 to 3 grains, should be given, 
followed by a full dose of castor oil. 

After the bowels have been moved a vermifuge, such as santonin, 
J to | of a grain, repeated in six hours, fluidextract of quassia, 10 to 
20 drops, given every six hours for three doses, or tincture of podophyl- 
lum 1 to 2 drops every six hours for three doses, may be administered. 

Ankylostomum Duodenale — Hookworm. — The hookworm is a 
nematode which inhabits the duodenum and jejunum. The female 
is about a half inch, and the male one-third of an inch in length. The 
body is thread-like. The head is conical; the mouth is bell-shaped, 
is surrounded by a horny capsule, and contains four hook-like teeth. 
These are ventrally situated, and on the dorsal side are two smaller 
vertical teeth by which the worm fastens itself to the mucous mem- 
brane. 



INTESTINAL WORMS 349 

The eggs are deposited in muddy water or in warm, moist earth, 
and there the embryos are liberated. These develop into larvae whieh 
soon pass into the dormant state and remain quiescent for an indefi- 
nite period until they are taken into the stomach by means of drinking 
water, food, or dirt — more commonly dirt that has collected on the 
hands, and particularly under the finger nails. 

Direct infection through the skin is now thought to be the usual 
mode of transmission, the parasite entering the body through the 
skin of the feet and legs by contact with contaminated soil. It then 
is carried by the blood stream to the lungs, passes into the air spaces, 
bronchi, trachea, esophagus, or stomach, and finally reaches the small 
intestine. Here sexual characteristics develop in the parasites, repro- 
duction ensues, and the ova are deposited in the bowel, but they do 
not multiply within the intestine. Males are affected with hook- 
worm to the same extent as females, and the parasite is most preva- 
lent in children between the ages of six and sixteen. 

Symptoms. — The symptoms of hookworm disease, or uncinariasis, 
are to be attributed chiefly to severe toxemia and anemia. There is 
usually abdominal discomfort or pain, progressive emaciation, and 
high-grade anemia resembling the pernicious form. Children who 
are infested have an apathetic, languid expression, and look much 
older than they really are. They are stunted mentally and physically, 
and become shiftless, untruthful, dishonest, disobedient, and closely 
resemble cretins. The face is puffy, the skin muddy and sallow, the 
abdomen distended, and the extremities are either very thin or swollen 
and edematous. 

These children have either a poor or ravenous appetite which is 
usually capricious, and they not infrequently eat earth and dirt, 
hence their name, " dirt-eaters." The subjective symptoms include 
headache, dizziness, palpitation of the heart, dyspnea, nausea, and 
spells of vomiting. The bowels are usually constipated, and the stools 
contain microscopic and occult blood. The changes in the viscera 
revealed at postmortem are cerebral anemia with effusion into the 
ventricles of the brain, flabbiness of the heart muscle, fatty degenera- 
tion of the liver, softening of the spleen, and the lesions typical of 
nephritis. 

Diagnosis. — A definite diagnosis can be made only by finding the 
ova and the hookworms in the stools, although the symptoms in 
most cases of uncinariasis are very characteristic. 

Prognosis. — The prognosis is good if the case is diagnosed early and 
is properly treated; but, occasionally, the disease runs a rapid course 
and the patient succumbs from exhaustion within a few weeks. 

Treatment. — Thymol is universally recognized as a specific for hook- 
worm disease. The maximum amount which should be given is 7J 
grains to children up to the age of five years, 15 grains to children 
from five to ten years, and 30 grains to those between ten and fifteen 
years. Two days before the thymol is to be given the diet should be 
restricted to liquids, and a dose of magnesium sulphate adminis- 



350 DISEASES OF THE G ASTRO-INT EST IN Ah TRACT 

tered, this being repeated on the following day. On the next day 
the thymol is given, one-half the dose at 6 a.m., and the remaining 
half at 8 a.m., followed two hours later by another dose of magnesium 
sulphate. The child should then be made to lie on the right side for 
two hours. 

This treatment should be repeated at the end of a week, and ten 
days later the stools should be examined for ova or parasites. If none 
is found, no more thymol need be given; but the child should have 
plenty of fresh air, good nourishing food, and should take a tonic 
such as Fowler's solution, 1 to 3 drops three times a day, or the 
syrup of the iodide of iron, 10 to 30 drops three times a day, for the 
anemia. 

Trichina. — The Trichina spiralis is a vivaporous worm occasionally 
found in children. The male, when mature, measures ■£$ of an inch, 
and the female T 1 ^ to ^ of an inch in length. The embryo is about 2V 
of an inch long, and lies coiled up in a spiral within an ovoid capsule 
in the sarcolemma sheath of the muscle fiber. The mature worm has 
a pointed, unarmed head. The neck is long and more slender than 
the body, which has a round, blunt end. 

The life history of the trichina begins when the larva? become 
encysted in the muscles. When this flesh is eaten by another animal 
or by man, the larva? are liberated by the digestive processes and pass 
into the intestines. In from two to four days they become sexually 
mature, and five to seven days thereafter they produce hundreds of 
living embryos. The intestinal trichina? reach their full growth and 
then die in from four to five weeks. 

During her life period in the intestine the female trichina may bring 
forth several broods of embryos. The living embryos migrate from 
the intestine at once, and invade the muscles through various channels, 
principally along the connective-tissue routes, so that the symptoms 
of muscular irritation develop in from seven to ten days after eating 
trichinous meat. 

The embryos attain maturity about two weeks after they invade 
the muscle tissue, where their presence sets up an irritation which 
in from four to six weeks causes the formation of a fibrous capsule 
about the trichina. Usually but one trichina is found within a cap- 
sule, and this encapsulated trichina may live for years in the muscle, 
the capsule finally becoming calcified so that it may be easily dis- 
cerned by the naked eye. 

Symptoms. — After meat infested with trichina? has been eaten there 
is usually a period of gastro-intestinal disturbance, followed by the 
symptoms of trichiniasis, which are not unlike those of influenza, 
rheumatic fever, malaria, or typhoid fever. There are severe pain and 
soreness in the muscles, and edema of the face^ and eyelids which 
suggests nephritis. These symptoms usually persist for from ten days 
to two weeks, during which time the disease is rarely recognized. 

Diagnosis. — A positive diagnosis can be made only by removing a 
section of muscle tissue, and identifying the trichina? within it. 



ACUTE PERITONITIS 351 

Treatment. — As soon as the diagnosis is made, thorough purging 
with calomel, 1 to 3 grains, should be instituted, and six hours later 
\ to 2 drams of magnesium sulphate should be administered. Further 
treatment is merely for the relief of symptoms, since it is doubtful 
whether anything can be done to arrest the progress of the disease 
after the muscles have once been invaded. 

Morphin sulphate, -V to to" °f a grain, may be given hypodermically 
for the relief of pain if simpler measures, such as warm baths and 
hot applications to the muscles, fail to give relief. Since deatli some- 
times occurs from exhaustion or the severe irritation, the child's 
strength should be kept up, and stimulation resorted to whenever 
necessary. 

Among the drugs said to be effective in destroying the trichina 1 arc 
glycerin, given in dram doses hourly, benzine in 5- to 20-grain doses, 
and picric acid in 1- to 2-grain doses. 



DISEASES OF THE PERITONEUM. 

ACUTE PERITONITIS. 

Acute peritonitis is extremely rare during childhood, and non- 
tuberculous chronic peritonitis is practically never encountered. 
Acute inflammation of the peritoneum is always a secondary process, 
although in some cases the primary factor may be very obscure. It 
may be circumscribed or diffuse, and is also classified as serous or sup- 
purative, according to the nature of the exudate. 

Etiology. — Peritonitis may occur in the fetus from syphilis or septic 
infection of the mother; but it is seen more frequently in the new- 
born than at any other period of childhood, and is the result of infec- 
tion of the umbilicus. Appendicitis is the most common cause of 
acute peritonitis in older children, but it is also occasionally seen in 
combination with inflammation of the abdominal viscera, lungs, pleura, 
or pericardium. Direct violence to the abdomen is responsible for 
a few cases; in other instances it may be traced to an attack of typhoid 
fever, pneumonia, one of the acute infectious diseases, or to gonorrheal 
vulvovaginitis. 

Perforation of an abdominal viscus, such as a rupture of the gall- 
bladder, abscess of the liver, ulcer of the duodenum or stomach, or 
a typhoid ulcer, always produces peritonitis. Sometimes infection 
may be transmitted from an empyema. Intussusception and stran- 
gulated hernia, if not reduced, are soon followed by peritonitis, and 
in rare cases the peritoneum has become infected through a ruptured 
cyst of the liver, spleen, or kidney. Occasionally the infection is 
carried through the blood stream, and in this manner peritonitis may 
complicate suppurative otitis media or an attack of meningitis. 
Infection by way of the lymph channels has also been proven. 



352 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

Bacteriological studies have shown that the colon bacillus, pneumo- 
eoccus, Staphylococcus aureus, Streptococcus pyocyaneus, and Strep- 
tococcus pyogenes are the organisms most frequently present. 
Gonococci may occasionally be found when peritonitis complicates 
gonorrheal vulvovaginitis; but this is rare. In appendicitis accom- 
panied by peritonitis, the colon bacillus has been isolated in the 
great majority of cases. Pneumococcal peritonitis, which has a special 
predilection for children, may complicate pneumonia or pneumo- 
coccemia; and peritonitis in which the staphylococcus or streptococcus 
predominates is usually due to an acute infectious disease or ruptured 
abdominal viscus. 

Pathology. — The postmortem findings depend altogether upon 
the character of the inflammatory process. In every case the visceral 
and parietal peritoneum is found to be intensely congested and 
hyperemic. If there be but little serous exudate, and the intestines 
are covered by an exudate of lymph, or are bound together by a 
fibrous exudate, fibrinous peritonitis is recognized. In serous peri- 
tonitis there is but little fibrin in the exudate, but a large amount 
of serum is found in the peritoneal cavity. 

Suppurative peritonitis is characterized by the formation of pus 
within the peritoneum. This is usually confined to that portion of 
the peritoneal cavity surrounding the site of infection, where an abscess 
forms; but in severe cases it may be present throughout the whole 
abdominal cavity. When a collection of pus is found walled off within 
the peritoneal cavity by the formation of inflammatory adhesions, 
the condition is known as circumscribed peritonitis, in contradistinc- 
tion to the diffuse form in which the pus is free. 

Symptoms. — In acute peritonitis the symptoms are usually very 
frank and acute; but occasionally they are masked by the primary 
and associated condition. This causes great difficulty in diagnosis, 
especially in infants during the first few days of the disease when the 
condition is not suspected. The prominent symptoms are pain, 
tympanites, absolute constipation, persistent vomiting, and high 
fever. Pain appears first at the point of infection, e. g., the right 
iliac fossa or umbilicus — but soon becomes general and extends over 
the whole abdomen. 

Vomiting is persistent, occurring usually at intervals, and increases 
in severity as the disease progresses. The vomitus is composed for 
the most part of a greenish, watery liquid which contains mucus. 
Hiccough is often distressing, and may be regarded as an unfavorable 
sign. In cases where there has been an antecedent diarrhea, this 
condition may persist; and, although constipation may afterward 
take its place as a result of paralysis of the intestinal muscles which 
inhibits peristalsis, diarrhea is more common in the peritonitis of 
childhood than in adults. 

There is usually an initial chill, followed by a sharp rise in tem- 
perature to 103° F. or even higher. The pulse is weak and rapid; 
the respirations are short and quick; and, while the body may be 



ACUTE PERITONITIS 353 

hot and dry, the extremities are cold. The tongue is dry and brown; 
the eyes are sunken; the child lies upon its back with its knees drawn 
up to relieve the tension upon the abdominal muscles. The urine is 
high-colored, concentrated, and scanty, or it may even be suppressed; 
upon examination it is found to contain an excessive amount of 
indican. There is always leukocytosis in peritonitis; but unless a 
blood count has been made before the disease is suspected this is of 
no diagnostic value, since it may be due to the primary condition — 
appendicitis. 

Physical examination in peritonitis reveals a distended, tender, 
tympanitic abdomen with marked rigidity of all the abdominal muscles. 
In circumscribed peritonitis the pain and tenderness are confined 
to the site of the abscess, and the symptoms are not as severe as 
in the diffuse form. Pneumococcal peritonitis, which is to a certain 
extent localized, is characterized by an encapsulated collection of pus 
behind the anterior abdominal wall just below the umbilicus, which 
forms a tumor at this point. 

In some cases of this variety of peritonitis, the skin about the navel 
becomes perforated and the abscess drains externally, whereupon 
recovery ensues. As a rule, the symptoms of peritonitis due to gonor- 
rheal vulvovaginitis are very mild, and the infection is confined to the 
pelvic peritoneum; but this form of inflammation of the peritoneum 
is not to be regarded too lightly, since the infection may spread through- 
out the peritoneal cavity and rapidly prove fatal. 

Diagnosis. — In children the diagnosis of peritonitis is difficult, and 
in infants the disease is often unrecognized. The history of an asso- 
ciated affection which might cause peritonitis and the physical signs 
are the most reliable points upon which to base the diagnosis. Dis- 
tention of the abdomen and extreme rigidity of the abdominal 
muscles, with persistent vomiting and severe constitutional disturb- 
ances, make up a group of signs and symptoms significant of acute 
peritonitis; but appendicitis should always be ruled out, if possible, 
by rectal examination. If this can not be done, and no other cause 
for the symptoms can be found, exploratory laparotomy is justifiable. 

Acute peritonitis may be differentiated from typhoid fever by its 
shorter and more acute course, by the relative severity of the symp- 
toms, and by the Widal reaction. Intussusception may resemble 
peritonitis, but it can be, differentiated by the absence of fever and 
the bloody, mucous stools which result from invagination of the gut. 

Prognosis. — Acute peritonitis is a fatal disease during infancy, and 
death usually occurs within the first few days. Pneumococcal peri- 
tonitis and diffuse peritonitis caused by the rupture of an abdominal 
viscus also present an unfavorable outlook. Gonorrheal peritonitis, 
however, ends in recovery in a great many cases. In circumscribed 
and traumatic peritonitis recovery depends upon the severity of the 
infection and the time when operation is performed. 

Treatment. — Surgical interference offers a better chance for recovery 
in most cases of acute peritonitis than does any other remedial measure. 
23 



354 DISEASES OF THE GASTRO-INTESTINAL TRACT 

Medical treatment is warranted only in those cases where peritonitis 
is due to mild trauma or an acute infection, or when it is associated 
with nephritis or gonorrheal vulvovaginitis; even in these cases, if 
the disease fails to respond to medication within two days, laparotomy 
is justifiable. Operation is always indicated when there has been a 
rupture of an abdominal viscus, and should be performed immediately ; 
for in diffuse peritonitis surgery avails but little if the condition has 
persisted for several days. Medical treatment of peritonitis consists, 
for the most part, in the relief of pain and in keeping the intestines at 
rest. The child should be kept in Fowler's position and cold applied 
to the abdomen for the first few days while the acute inflammatory 
symptoms persist. 

If one feels sure that there is no danger of perforation of the intes- 
tines, a thorough purge of \ to 2 drams of magnesium sulphate should 
be given. Nothing should be taken by mouth until vomiting ceases; 
but the child may be allowed to suck cracked ice if the mouth is 
parched. After the first three or four days warm applications, turpen- 
tine stupes, and poultices may be put on the abdomen, and the child 
be given whiskey or brandy in 5- to 20-drop doses at frequent inter- 
vals during the day. So long as the stomach rejects food, nourish- 
ment may be furnished by means of nutrient enemata; but, as the 
patient's condition improves, the breast-fed infant may resume its 
nursing and the bottle-fed baby be given small quantities of a weak 
milk mixture, gruel, or broth. 

When the temperature runs very high the child may be sponged with 
tepid water or rubbed with alcohol. If tympanites becomes severe, 
a long rectal tube may be inserted into the bowel and allowed to 
remain there for several hours. If stimulation is indicated, champagne 
or whiskey in 5- to 20-drop doses should be given at frequent intervals, 
and strychnine sulphate, grain -g-j-g- to grain 2T0-, or camphorated oil, 
1 to 5 drops, may be administered hypodermically. The intestines 
may be kept immobile by hypodermic injections of morphine sulphate, 
grain eV to 2V, combined with atropine sulphate, grain T cro to 5^; 
the morphine thus given will also alleviate the pain. 

In addition to these immediate measures, much can be done to 
improve the general condition of the child by giving it good hygienic 
care, plenty of fresh air, and by sending it away to the seashore or 
country during convalescence. 

The treatment of circumscribed peritonitis is essentially surgical, 
and consists of incision and drainage, followed by the tonic measures 
outlined above. 

CHRONIC PERITONITIS. 

Chronic peritonitis which is not caused by the tubercle bacillus is 
of such extreme rarity during childhood that its occurrence is doubted 
by various competent authorities. This, however, applies only to 
diffuse inflammation of the peritoneum, for localized chronic peri- 
tonitis may accompany disease of any of the abdominal viscera. 



CHRONIC PERITONITIS 355 

Etiology. — The exact cause of this form of chronic peritonitis is 
never clear, but it may follow measles, rheumatism, exposure, or 
injury. The visceral layer of peritoneum becomes inflamed, while 
the organ which it covers becomes diseased, and circumscribed peri- 
tonitis of chronic type may follow appendicitis. Chronic non-tuber- 
culous peritonitis usually occurs after the fifth year. 

Pathology. — Chronic peritonitis may be either localized or diffuse, 
serous or fibrinous. The serous form, or peritonitis with ascites, is 
characterized by the accumulation of a large quantity of straw-colored 
fluid within the peritoneal cavity. There is only a relatively small 
amount of fibrinous exudate, and few adhesions are found. This 
picture is far different from that of fibrinous, dry, or proliferative 
chronic peritonitis in which the abdominal cavity contains little fluid, 
but the intestines are covered with fibrin, and bound down and 
matted together by fibrous adhesions. In chronic localized peritonitis 
there is an increase in fibrous tissue over the serous covering of an 
abdominal viscus or about an area of preceding inflammation within 
the peritoneal cavity — for example, appendicitis or salpingitis. 

Symptoms. — The symptoms of chronic peritonitis come on most 
insidiously. Enlargement of the abdomen is usually the first percep- 
tible sign of disease within the abdominal cavity, although there 
may have been gradual loss of weight and strength, and indefinite 
and vague symptoms, such as slight pain and tenderness of the 
abdomen. Dyspepsia usually precedes the collection of ascitic fluid. 
The appetite is generally poor; the bowels are alternately constipated 
and loose. There is usually slight fever, highest in the evening, and 
the child has secondary anemia from malassimilation and indigestion. 
In some cases there is marked disturbance of the general nervous 
system, but, as a rule, convulsions do not occur. 

On inspection, in ascitic cases, the abdomen usually appears to be 
enlarged and distended, and a fluctuation wave can be detected. The 
area of flatness on percussion will be found to change with change in post- 
ure, and its exact extent varies according to the amount of fluid present. 

In dry, or plastic, peritonitis, occurring in thin or emaciated chil- 
dren, the greatly thickened and rolled-up omentum may sometimes 
be palpated. Chronic non-tubercular peritonitis runs a very irregular 
course with alternating periods of relapse and improvement; but in 
many cases the fluid is slowly absorbed, and permanent recovery 
usually follows. 

Diagnosis. — The most important point in the diagnosis of chronic 
non-tubercular peritonitis in a child is the presence of ascitic fluid 
in the abdomen with absence of any disease of the heart, liver, or 
kidneys, and no demonstrable tuberculous lesion. Tuberculosis must 
always be excluded in these cases, although this exclusion is invariably 
an extremely difficult task. 

Failure to find a tuberculous lesion in other parts of the body is not 
conclusive evidence against tuberculosis, neither is a negative von 
Pirquet reaction. Moreover, examination of the ascitic fluid for the 



350 DISEASES OF THE GASTRO-INTESTINAL TRACT 

tubercle bacillus is of little value in determining its presence, since it 
is often impossible to find it in known tubercular peritonitis. But 
when, in a given case, all of these determining factors are negative 
and when guinea-pig inoculation with the ascitic fluid also fails to 
give a tuberculous reaction, one is justified in pronouncing the case 
non-tubercular. 

Prognosis. — The prognosis of chronic non-tubercular peritonitis is 
more favorable in the child than in the adult, and a number of cases 
end in complete recovery. There is always, however, the danger 
of death from an intercurrent infection or from extreme debility and 
exhaustion. The prognosis should be guarded in every case, because 
of the difficulty of definitely excluding tuberculosis. 

Treatment. — Rest in bed and a carefully regulated and nourishing 
diet should be insisted upon. The child should also be given tonics, 
such as the syrup of the iodide of iron, 10 to 30 drops, tincture of nux 
vomica, 2 to 5 drops, or cod-liver oil in teaspoonful doses after meals; 
but the physician should watch to see that this medication does not 
impair the appetite. The bowels must be regulated by the adminis- 
tration of fluidextract of cascara sagrada (aromatic), 15 to 40 drops, 
or the compound syrup of rhubarb, J to 1 dram. If the absorption 
of the ascitic fluid is very slow, saline cathartics, such as either mag- 
nesium sulphate or Rochelle salts, \ to 1 dram, should be employed 
routinely. 

When these measures fail, and the accumulation of fluid becomes 
so great as to cause discomfort, the abdomen should be tapped with 
a trocar and the fluid slowly withdrawn. If it rapidly reaccumulates 
after each tapping, great improvement, and sometimes recovery, can 
be brought about merely by opening the abdomen and washing out 
the peritoneal cavity with warm normal saline solution. 

ASCITES. 

Ascites is an accumulation of serum in the peritoneal cavity. It 
is usually due either to obstruction of the portal circulation or inflam- 
mation of the peritoneum, although a dropsical condition of the 
peritoneum with no apparent cause also occurs, and is more common in 
children than in adults. 

Ascitic fluid is usually clear, straw-colored, alkaline in reaction, 
with a specific gravity of 1010 to 1015; under the microscope it is 
found to contain leukocytes, red corpuscles, endothelium, fat cells, 
and cholesterin crystals. When ascites is due to malignancy Dr to 
tuberculous peritonitis the serum may be blood-stained, and it is 
occasionally also bile-stained. In chylous ascites the accumulated 
fluid has a milky appearance, and contains fat droplets, sugar, and a 
few lymphocytes. 

Etiology. — Ascites is frequently associated with general edema in 
cases of nephritis, cardiac disease, chronic pleurisy, pernicious anemia, 
and leukemia. It is also a prominent symptom in most cases of peri- 



ASCITES 357 

tonitis in children, especially those due to tuberculous infection. A 
common cause is portal obstruction, which may be the result either 
of diseases of the liver, such as cirrhosis, syphilis, lardaceous disease, 
or hepatic tumors, or of interstitial pneumonia, thrombosis of the 
portal vein, pressure of abdominal tumors, or obstruction of the vena 
cava by enlarged retroperitoneal lymph nodes. 

Simple dropsy, or that form without apparent cause, is in all prob- 
ability in most instances due to subacute peritonitis. Chylous ascites 
is due to obstruction of, or injury or ulceration along the thoracic 
duct; it is sometimes observed in association with tuberculosis of the 
mesenteric glands. 

Symptoms. — The symptoms of ascites are very mild and usually 
imperceptible until the accumulation of fluid is large enough to cause 
a sensation of weight and pressure in the lower abdomen. As the 
amount of fluid increases, the symptoms due to pressure become 
more decided, and constipation, dragging pains in the loins, dyspnea, 
and frequent micturition result. 

At this stage the presence of fluid in the abdomen is quite obvious, 
and in some cases the abdomen becomes enormously large, the 
enlargement being symmetrical. The superficial veins in the skin 
about' the umbilicus are distended and prominent, and a fluctuation 
wave may easily be detected. On percussion there is flatness in the 
flanks, also tympany over the centre of the abdomen while the child 
lies on its back, with alteration in the areas of flatness and tympany 
on change of posture. The liver, spleen, and even the heart are 
pressed upon by the accumulated fluid, and finally displaced. 

Diagnosis. — The diagnosis of ascites should be based upon a history 
of one of the causative factors that have been mentioned, together 
with the physical signs and symptoms of an unsacculated accumula- 
tion of fluid within the peritoneal cavity. On seeking in a given case 
to find the cause of ascites, examination of the heart, blood, and urine 
will quickly show whether cardiac disease, anemia, or nephritis is the 
underlying cause, while removal of the ascitic fluid followed by deep 
abdominal palpation will often reveal the presence of a tumor in those 
cases due to portal obstruction by a neoplasm. 

Abdominal cysts may grow so large that they closely simulate 
ascites, hence such conditions as hypernephroma, ovarian cysts, and 
hydatid disease of the liver must always be excluded. The protuberant 
abdomen seen so often in children w T ith chronic intestinal indigestion, 
rachitis, or marasmus, sometimes suggests ascites; but careful physical 
examination will reveal no shifting flatness or tympany on change of 
posture, no fluctuation wave, and the apparent distention of the 
abdomen will disappear when the child lies down. Chylous ascites 
can be diagnosed only when some of the ascitic fluid has been with- 
drawn from the abdominal cavity and examined. 

Prognosis. — Ascites is but a symptom, not a disease; therefore the 
prognosis depends upon the underlying factor. Except in idiopathic 
or simple dropsy, the outlook is generally unfavorable. 



358 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

Treatment. — Obviously the most essential point in curing ascites 
is to remove the cause, all other measures being designed merely 
to alleviate the symptoms caused by the presence of the fluid within 
the abdominal cavity. The child should be placed on a light nutri- 
tious diet containing a high nitrogen content, and the liquid intake 
restricted as much as possible. 

Hydragogue cathartics, such as magnesium sulphate, dose 20 to 60 
grains, or powdered jalap, dose 1 to 3 grains, and diuretics such as 
potassium bitartrate, 5 to 20 grains, or digitalis leaves powdered, yV 
to 1 grain, or powdered squills, 2V to \ of a grain, should be given 
in order to drain the tissues of fluid and promote the absorption of 
the ascitic serum in the peritoneum. Tonics, such as the syrup of 
the iodide of iron, dose 10 to 30 minims, or the saccharated carbonate 
of iron in \- to 1-grain doses, are speciaelly beneficial in ascites due to 
anemia, or in so-called simple dropsy. 

If, in spite of the treatment above outlined, absorption of the 
fluid does not take place and the pressure symptoms become worse, 
the abdomen should be tapped and the serum withdrawn slowly 
through a trocar. Several hours should be consumed in completely 
draining off the fluid, and the abdomen should be tightly bandaged 
during and after its removal in order to prevent such a sudden and 
great fall in intra-abdominal pressure as would produce harmful 
consequences. 

INGUINAL HERNIA. 

Inguinal hernia is not an uncommon affection in childhood, occur- 
ring most frequently in little boys. Three forms are recognizable; 
the congenital, funicular, and infantile. The congenital type is that 
in which a loop of intestine forces its way through the still open 
funicular process, and thus effects entrance to the scrotum, where it 
usually surrounds the testicle. 

In the funicular type the tunica vaginalis is shut off from the funic- 
ular process above the testicle, so that the hernia occupies the 
funicular canal, but does not envelop the testicle. The infantile, or 
encysted, form is very rare, and can be diagnosed only at operation. 
The intestine, encased in a pouch of peritoneum, forces its way into 
the funicular process and descends, although this canal is closed above 
and open below. 

Etiology. — Hernia may exist at birth or it may develop as the child 
grows older and begins to lead an active life; but in children it is 
always regarded as a congenital condition. It usually occurs on the 
right side, but both sides may be involved, and thus give rise to a 
double inguinal hernia. Boys are more frequently affected with hernia 
than girls because of the presence in boys of the inguinal canal, which 
is a weak spot made by the testicle in its descent to the scrotum. 

The infant is predisposed to hernia because of the relatively short 
and direct course of the inguinal canal, which allows easy passage of 
the gut through the internal ring if this inner opening is not entirely 



INGUINAL HERNIA 359 

closed, or it' the peritoneum at this point is weak or lax. Femoral 

hernia, on the other hand, is very rare in children because of the 
proximity of the pubic spine, the anterior spine of the ilium, and Pou- 
part's ligament, which in the child lie so close together that there is 
really insufficient space for a hernia to form. It is more common 
in girls than in boys. 

Pathology. — The hernial sac usually contains loops of the small 
intestine, and only occasionally is the omentum found within it. 

Symptoms. — In most cases the only symptom is the presence of 
a tumor in the inguinoscrotal region. This tumor becomes smaller 
when the child lies down, and again enlarges when the upright position 
is assumed, or whenever intra-abdominal pressure is increased by 
crying or coughing. Upon examination the external ring is found to 
be enlarged, an impulse is transmitted to the tumor during coughing, 
and the mass on being manipulated and pushed back into the abdomen 
makes a gurgling sound. The entire scrotum may be filled by the 
tumor, so that it is difficult to palpate the testicles, but they can 
usually be found above and behind the coils of intestine. It is important 
that both testicles be located in order to eliminate the possibility of 
an undescended testicle. When an inguinal hernia occurs in girls, 
the tumor occupies one of the labia majora. 

Diagnosis. — The diagnosis of inguinal hernia is more perplexing in 
children than in adults because of the possibility of mistaking it for 
other conditions which may produce a tumor in this location during 
childhood, also because of various affections which may coexist with 
hernia, such as a cyst of the spermatic cord, a hydrocele, or an 
undescended testicle. Congenital hydrocele, which is comparatively 
common in children, presents the following differentiating features: 

Hernia. Hydrocele. 

Reducible, accompanied by gurgling on Irreducible, or slowly so, with no 

reduction. gurgling sounds. 

Dulness or tympany on percussion. Flat on percussion. 

Increase in size on crying and coughing. Xo change in size. 

Impulse on coughing. Xo impulse. 

Opaque. Translucent. 

Encysted hydrocele of the cord presents the same differentiating 
features as congenital hydrocele; but, owing to its movability, it 
may be pushed into the internal ring and an apparent reduction thus 
be accomplished, which is very confusing. The scrotum should 
always be carefully examined in order to determine the position of 
the testicles; for if they can be located in this manner undescended 
testicle can be ruled out. If the testicle is not found on that side of 
the scrotum in which there is a tumor, the hernia is probably compli- 
cated by an undescended testicle, and on examination of the mass the 
testicle will be felt as a firm hard tumor which is tender and painful 
on pressure. There is no pain or tenderness associated with uncom- 
plicated hernia, and the tumor is elastic and soft. 

Femoral hernia can be easily distinguished from the inguinal variety 



360 DISEASES OF THE GASTRO-INTESTINAL TRACT 

by the location of the tumor just beneath the saphenous opening, 
with its origin from the outer side of the pubic spine; while the origin 
of inguinal hernia is from the inner side of the spine of the pubic bone. 
Enlarged inguinal glands, while sometimes giving rise to a tumor 
resembling that of hernia, are easily differentiated, for on palpation 
they are found to be hard, firm, and non-reducible; they transmit 
no impulse; and are accompanied by enlargement of the whole chain 
of glands in this region. 

Complications. — In addition to other congenital conditions, such as 
undescended testicle and hydrocele, hernia may be complicated by 
obstruction of the bowels caused by strangulation of the loop of intes- 
tine caught within the hernial sac. This occurrence, however, is quite 
rare in children because of the elasticity of the tissues of the inguinal 
canal; but, strange as it may seem, it happens more frequently in 
infants than in older children. In the child the symptoms of stran- 
gulation are very acute; there is sudden pain, with vomiting and 
absolute constipation after the fecal contents of the bowel below the 
obstruction have been passed. The hernia is irreducible and very 
painful; the child lies with the leg on the affected side drawn up to 
the abdomen. 

Prognosis. — The prognosis in uncomplicated hernia in the child is 
very favorable, and in the majority of cases recovery ensues if properly 
fitting appliances are obtained and worn to keep the hernia from com- 
ing down into the inguinal canal. 

Treatment. — Operation for the cure of hernia is necessary only in 
older children; for, during the first few years of life, the application 
of a truss, which must be worn continuously day and night, will 
generally effect a cure. If the wearing of a truss is successful it 
will bring about obliteration of the hernial sac, and close the ring 
within a year, so that, at the end of this period, the pressure on the 
ring can be removed and the tumor will not appear. But the truss 
should always be worn for at least six months after this time in order 
to prevent recurrence. 

When a child is wearing a truss, the physician in charge of the 
case should instruct those in attendance to see that the pressure upon 
the hernial opening is never relaxed; for if the hernia should reappear 
during bathing, and this should happen frequently, it will indefinitely 
postpone cure. Care should also be taken to see that the skin beneath 
the truss pad does not become irritated or excoriated, and to this 
end special effort must be made to keep the skin in this region dry. 
As the child grows, the truss should frequently be made larger to 
accommodate the increasing size of the child; but it should not be 
worn indefinitely. 

After the second year the prospect of cure by non-operative means 
diminishes greatly, so that operation is advisable if the condition 
persists without improvement. Owing to the difficulty of properly 
fitting a truss for femoral hernia, operation is advisable in children 
as soon as the patient's general condition will allow it. If inguinal 



PROCTITIS 361 

hernia becomes incarcerated or strangulated, operation is imperative, 
and should be performed immediately. 

The results of operation in uncomplicated hernia? are so favorable 
that it is unquestionably the surest and safest mode of cure, provided 
the child is old enough and strong enough to survive the operation. 
In children suffering from hernia the bowels should be kept regular 
before and after operation, and after a cure has been effected, either 
by operation or non-operative measures, active exercise should be 
prohibited for months, in order to prevent a possible recurrence. 

Strangulated or incarcerated hernia calls for immediate reduction 
by taxis and manipulation, or by operation. In attempting to reduce 
a strangulated hernia, which is an easier procedure in the child than 
in later life, the child should first be placed in a warm bath to relax 
the muscles, and then a few drops of ether be administered. If the 
contents of the hernial sac can not be pushed back, immediate opera- 
tion is demanded, the nature and extent of which will depend upon 
the condition of the strangulated intestine. If gangrene is present, 
resection is advisable, and in older children the shock of resection i> 
frequently borne quite well, although it is usually fatal in infants. 



DISEASES OF THE RECTUM AND ANUS. 



PROCTITIS. 

Proctitis, or inflammation of the rectum, is not uncommon during 
childhood, and may be either primary or secondary. Of the simple 
varieties the catarrhal is the most common, and the membranous and 
ulcerative types are the most infrequent. The specific form is rare; 
it is spread from the genitalia in cases of gonorrheal vaginitis and 
diphtheritic vulvovaginitis . 

Etiology. — Among the primary causes of proctitis must be included 
trauma (although this is rare), threadworms, the use of drastic pur- 
gatives, and rough manipulation of thermometers and syringe nozzles 
when inserted within the rectum. The prolonged use of soap or 
glycerin suppositories may also produce irritation and inflammation 
of the rectum. Proctitis occurs secondarily in cases of gastro-enteritis, 
dysentery, prolapse of the rectum, and rectal polypi. 

Except when it accompanies general diphtheritic infection, the 
membranous form is more often due to the streptococcus than to the 
Klebs-Loeffler bacillus; while gonorrheal proctitis is, in the majority 
of cases, caused by a spreading of the profuse discharge from the 
vagina backward into the anus, but may also be produced by careless 
handling of thermometers and syringe nozzles. 

Pathology. — In catarrhal proctitis the mucous membrane is swollen 
and hyperemic, and there is an exudation of blood-stained mucus. 
The ulcerative form is but a more advanced stage of the catarrhal 



362 DISEASES OF THE GASTRO-INTESTINAL TRACT 

type, and is marked by the formation of large superficial ulcers scat- 
tered throughout the rectum. Follicular ulceration of the rectum is 
also occasionally seen in association with follicular ulcerative colitis; 
in this type the ulcerations, while small, are quite deep, extending far 
down to the muscular coat of the bowel. 

In membranous proctitis many superficial ulcerations form; they 
are covered with a grayish-white membrane which is very tenacious 
and leaves a raw, bleeding surface when removed. Gonorrheal infec- 
tion of the rectum gives rise to a severe catarrhal inflammation, dis- 
tinguished by an excessive purulent secretion. 

Symptoms. — Among these, rectal tenesmus is the most prominent, 
and is extremely severe during defecation, the pain lasting a con- 
siderable time after each bowel movement. The child is usually 
constipated, but there are frequent discharges from the rectum of 
bloody mucus which may or may not be mixed with feces. The stools 
contain shreds of mucus and, in the diphtheritic type, sometimes 
casts of the rectum. In ulcerative proctitis much blood is usually 
passed by the bowel. In gonorrheal proctitis the discharge from the 
rectum is distinctly purulent and, if examined microscopically, may 
be found to contain the gonococcus. Prolapse of the rectum quite 
often accompanies the condition as a result of the straining and 
tenesmus at stool. 

Treatment. — The child suffering with proctitis should be put to 
bed, and kept upon a nourishing liquid diet which will not cause con- 
stipation. If necessary, the stools can be kept loose by the adminis- 
tration of mild laxatives, such as the syrup of rhubarb, in 20- to 60- 
drop doses, or milk of magnesia, 1 to 2 teaspoonfuls at a dose. Pain 
may be relieved by the use of suppositories of gV to \ grain of opium 
or yo to | grain of cocaine, or by painting the mucous membrane of 
the rectum with cocaine solution. 

Sweet oil, olive oil, saline solutions, lime-water, boric acid, and 
potassium permanganate may all be used for injection in the catarrhal 
form of the disease; but care should be taken not to further irritate 
the already inflamed rectum. 

In the ulcerative form a weak astringent, such as \ of 1 per cent, of 
silver nitrate solution, is very effectual, while in gonorrheal proctitis 
injections of antiseptic solutions, such as tincture of iodine, a half- 
dram to a pint of water, or 1 to 2000 silver nitrate solution, or a 1 
per cent, solution of protargol or witchhazel, are all indicated. In 
diphtheritic proctitis the child should be given large doses of anti- 
toxin in addition to the local treatment. 

PROLAPSE OF THE RECTUM (PROCIDENTIA RECTI). 

Prolapse of the rectum may be either partial or complete, according 
to whether the mucous membrane alone or the entire rectal wall pro- 
trudes from the anus. Partial prolapse, or prolapse of the anus, as 
it is sometimes called, is due to relaxation of the mucous membrane 



PROLAPSE OF THE RECTUM 

which, to a certain extent, becomes detached from the muscular coat 
of the rectum underlying it, and is everted by the straining at stool. 

It may, perhaps, return to its place after each movement of the bowels, 
and the affection usually shows a tendency to spontaneous cure. 

A predisposition to total prolapse may be accounted for by the 
almost vertical position of the rectum during infancy and early child- 
hood, and by its weak attachments which fail to hold it in place. 
Constipation and diarrhea, as well as dysentery which causes severe 
tenesmus and straining, are the most frequent causes of rectal prolapse, 
owing to the increased abdominal pressure they produce. 

Other conditions, such as fecal concretions, rectal polypi, vesical 
calculi, and irritation of the rectum, bladder, or genitalia, from other 
causes, may be contributory factors. Pertussis may produce it 
because of the increased abdominal pressure during paroxysms of 




Fig. 31. — Procidentia recti: cretin eight years old. 

coughing. Rectal prolapse occurs most commonly in children under 
three years of age, especially if they are undernourished, weak, or 
anemic, and is not infrequent in rachitic children (Fig. 31). 

Symptoms. — In cases of prolapse of the anus inspection reveals an 
everted mass of mucous membrane which may be covered with mucus 
and blood, and surrounds the anal orifice. It has a central aperture, 
and is easily reducible. Prolapse of the rectum forms a much longer 
and thicker mass, with an orifice in the centre of the distal end. The 
mucous membrane is at first bluish-red in color, and shows marked 
congestion. 

Later, if the prolapse is not reduced, ulceration may develop, pain 
become severe, and the tumor swells and bleeds constantly. Reduction 
is now difficult; but if the case is seen just after prolapse has occurred 
it can usually be corrected merely by manipulation. 



364 DISEASES OF THE GASTRO-INTESTINAL TRACT 

Diagnosis. — Actual prolapse of the rectum is easily diagnosed by 
inspection; but sometimes rectal polypi and intussusception may 
simulate a prolapse, in which case the examining finger can be inserted 
between the tumor and the rectal wall, which obviously would be 
impossible in rectal prolapse. 

Treatment. — In mild cases, the tumor can usually be replaced by 
simple manipulation, and this should be done after every bowel move- 
ment which brings on a prolapse. A suppository of tannic acid, 2 
grains, or some other astringent, should be inserted within the rectum 
as soon as the prolapse has been reduced; a cold-water douche after 
each bowel evacuation will strengthen the muscular tone of the 
rectum. 

Severe cases of prolapse require the application of cold to the 
swollen and inflamed tumor, and in some instances it may be found 
necessary to administer a few whiffs of chloroform to relax the con- 
tracted muscles before the rectum can be pushed back into position. 
The child should be laid upon the lap, face down, with the legs higher 
than the buttocks, while reduction is being accomplished, and after 
the rectum has been replaced the buttocks should be held together 
by strips of adhesive plaster in order to prevent another prolapse. 
In severe cases rest in bed is advisable, and should be insisted upon 
until marked improvement takes place. Even in mild cases the child 
should always lie down before his bowels move. 

In addition to these immediate measures, much can be done to 
benefit these children by ascertaining and removing the cause of the 
prolapse, whether it be constipation, diarrhea, intestinal parasites, 
rectal polypi, or any other source of irritation which increases intra- 
abdominal pressure or straining at stool. The bowels should be 
regulated and kept slightly loose. An effort should also be made to 
build up the child's general health by a nourishing diet, improved 
surroundings, and other hygienic measures. 

Under this treatment the ordinary case of prolapsed rectum will 
recover unless the sphincter ani has altogether lost its tonicity, when 
operation will be necessary. But surgical procedures which, in the 
adult, are attended by excellent results may be much too severe for 
the child; therefore, as a general rule, we should choose the simplest 
operation which will give results. Thus, fixation of the rectum at a 
higher level is too formidable, hence is contraindicated, and scarifica- 
tion of the mucous membrane with the actual cautery or amputation 
of the prolapsed portion of rectum should be chosen instead. 

RECTAL POLYPI. 

These growths in the rectum are rarely found in infants, but the 
condition is not uncommon during later childhood. They are usually 
pedunculated, but may have a sessile base, and consist merely of 
hypertrophied mucous membrane. As a rule, there is but one polypus 
present, and that is commonly situated on the posterior wall of the 



FISSURE IN ANO 365 

rectum just above the internal sphincter. These tumors may be 
either adenomata, myxomata, or fibromata. They are hard and 
firm, and are composed of villi and rugae of the mucous membrane. 
In exceptional cases the rectum may be nearly filled with small 
tumors. 

Symptoms. — The most common symptoms of rectal polypi are 
tenesmus, prolapse, and hemorrhage from the bowel. Pain is very 
severe whenever the bowels move, and the stool is covered with bright 
red blood. 

Diagnosis. — The diagnosis should be made only after digital exam- 
ination and exploration of the rectum with a speculum and reflected 
light. 

Treatment. — When the growth is pedunculated it may be easily 
ligated at the base and snipped off. Sessile tumors are quite difficult 
to remove, and a rectal speculum should be used in order to see that 
the ligature embraces all of the stump. After removal of polypi, 
an opium suppository or iodoform ointment should be inserted in 
the rectum to relieve the pain. It is dangerous to allow these growths 
to remain in the rectum, since they are apt to become malignant. 

HEMORRHOIDS. 

Children rarely suffer from hemorrhoids, but either the external 
or internal variety may occasionally be observed. They are practically 
never seen in infancy, but are less rare as the child advances beyond 
the third year. 

Etiology. — The most common cause of these growths is chronic 
constipation. 

Symptoms.— The internal form of hemorrhoids is the only one likely 
to be met with in children, so that usually no tumor is found on inspec- 
tion of the anus. The only important symptoms are pain and the 
passage of stools containing bright red, unchanged blood. 

Treatment. — The bowels should be kept loose by the administration 
of cascara sagrada, 10 to 30 drops, each evening, or milk of magnesia, 
1 to 3 drams. The anus should be kept clean, and the lower rectum 
flushed with salt solution twice a day, after which an astringent oint- 
ment containing 2 per cent, of tannic acid may be applied, or the 
following solution may be injected into the rectum each morning: 

1$ — Acidi tannici gr. ij 

Ichthyoli 5ss 

Alcoholis 3J 

Aqua . . q. s. ad. flSiss 

Sig. — Use as injection each morning. 

FISSURE IN ANO. 

Fissure of the anus is usually the result of severe constipation, and 
is caused by the stretching of the anal mucosa in passing large hard 
fecal masses. In exceptional cases it is produced by rough manipula- 



366 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

tion of the nozzle of a syringe or rectal tube, and occasionally it 
is associated with eczema of the anus and the presence of intestinal 
parasites. 

Symptoms. — Pain is so extremely severe and agonizing when the 
bowels are moved that the child voluntarily retains the feces within 
the bowel as long as possible, thus increasing the constipation and 
aggravating the condition. Bright red blood may appear upon the 
diaper or in the stool. 

Diagnosis. — The diagnosis is made by physical examination, which 
reveals in acute cases a small narrow break at the mucocutaneous 
junction, and an ulcerated area if the fissure be chronic. 

Treatment. — The bowels should be kept moving freely by the use 
of laxatives to prevent the formation of hard masses of feces. The 
mucous membrane should be thoroughly cleansed every day with a 
mild antiseptic solution, such as a saturated solution of boric acid, 
and the fissure then touched with a 10 per cent, solution of nitrate of 
silver. Relief is often afforded by keeping the anus well greased with 
vaseline or oxide of zinc ointment containing 1 per cent, of phenol. 
If there is any tendency to chronicity the anus should be forcibly 
dilated with the fingers. 

SPASM OF THE ANUS. 

Spasm of the anus is most commonly associated with fissure in ano, 
but may happen also in neurotic children when no organic lesion exists. 

Symptoms. — Tenesmus and pain during defecation are the principal 
symptoms. Constipation is caused by the natural aversion of the 
patient to evacuate the bowels because of the pain which the act 
produces. Examination of the anus in these cases will reveal a 
markedly contracted sphincter ani. 

Treatment. — The bowels should be regulated by the administration 
of mild laxatives, such as aromatic syrup of rhubarb, J to 1 fluidram; 
cascara sagrada, 1 to 2 grains; or milk of magnesia, 1 to 2 drams. 
Injections of olive or sweet oil also render the lower end of the rectum 
less sensitive; but care should be taken not to cause irritation. 

In some cases it may be found necessary forcibly to dilate the 
sphincter. • The following prescription will be found valuable in 
inhibiting rectal spasm, and is especially useful if there is a slight 
abrasion of the mucous membrane or a fissure in the anus: 

1$ — Unguenti belladonnae, 

Unguenti hyoscyami aa 5ij 

Petrolati q. s. ad. gj 

Sig. — Apply freely. 

ANAL FISTULA. 

Anal fistula? are rare during childhood, but may occasionally be 
the sequelae of proctitis and hemorrhoids. In many cases the infection 
is tuberculous. The course of the disease is usually chronic. 



ISCHIORECTA L A BS( 'ESS 36i 

Symptoms. — The affection first manifests itself as a small abscess 
in the cellular tissue surrounding the anus. Instead of forcing its 
way to the surface and rupturing externally, this abscess burrows into 
the surrounding tissues. The openings of the fistula are usually quite 
small, even though the fistulous tract is long and tortuous. When 
one opening is in the rectal mucous membrane and the other on the 
skin surface the fistula is called a complete one. 

A complete internal fistula is one which has both openings in the 
mucous membrane, and a complete external fistula is one with both 
of its openings on the skin surface. Blind fistulae have but one open- 
ing, and may be either internal or external, according to whether that 
opening is on the skin or in the rectum. External fistulae manifest 
themselves by the formation of this opening on the skin which does 
not heal, and continually discharges pus. If the fistula is internal, 
pruritus often accompanies it, and is thought to be due to irritation 
of the anus by the pus which exudes from the orifice of the fistula 
within the rectum. 

Diagnosis. — The subjective symptoms are very mild, and until pus 
is detected oozing from one of the orifices the existence of the affec- 
tion may not even be suspected. If, however, such an opening be 
found, the diagnosis is easily confirmed by inserting a probe and fol- 
lowing its course. In this manner, also, the nature of the fistula 
can be determined; or, better still, the course and ending of a fistulous 
tract can be ascertained by injecting hydrogen peroxide into one 
orifice, and noting its appearance at the other. 

Treatment. — The treatment of fistula in ano is surgical. If the 
fistula is complete, the entire length of the tract should be incised and 
laid open; if incomplete, it should be converted into a complete one 
by artificially continuing the tract until it has an internal opening 
into the rectum, and then be incised. After incision the pyogenic 
membrane lining the fistulous tract should be curetted away, and the 
cavity packed with iodoform gauze. By these means a cure is usually 
brought about, but relapses are common. 

ISCHIORECTAL ABSCESS. 

An ischiorectal abscess is one which forms in the ischiorectal fossa 
midway between the anus and the tuberosity of the ischium, and is 
due to infection from an abrasion, fissure, or ulceration of the rectum 
or anus. The lymph nodes about the rectum first become involved, 
and thence the invading organisms effect entrance into the fossa. 
Occasionally the abscess is tuberculous as a result of tuberculosis 
of the bony pelvis. 

Symptoms. — Tenderness, induration, swelling, and redness are 
found on the affected side; but no fluctuation can be detected until 
late in the course of the disease, owing to the depth of the abscess 
and the density of the fascia. Defecation is painful. The child can- 
not bear its weight on the affected buttock while sitting down. The 



368 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

temperature usually runs high, and other constitutional symptoms of 
pus formation appear. 

Treatment. — The abscess should be freely incised and the cavity 
washed out with hydrogen peroxide, after which free drainage should 
be kept up until the discharge of pus ceases. If the case is one of 
tubercular infection, the abscess should be opened and the affected 
bone curetted. After the cavity is perfectly clean it should be closed 
without drainage. 

If pus formation again becomes evident, the same treatment should 
be repeated, and several incisions of the abscess are sometimes required. 
It is well to give these children a purgative dose of castor oil. If 
tuberculosis be evident they should be kept out of doors, put on a 
nourishing diet, and sent away to the country, mountains, or seashore 
if practicable. 



DISEASES OF THE LIVER. 

Organic diseases of the liver are extremely rare during childhood; 
on the other hand, this organ frequently becomes affected during the 
course of the acute infectious diseases so common among children. 

SIZE AND LOCATION OF THE LIVER. 

The liver is relatively much larger in the child than in the adult, 
its weight being from ■%■$■ to 2V °f the entire weight of the body. At 
birth it weighs about four ounces (128 Gm.), which is approximately 
4 per cent, of the body weight; but its subsequent growth is not in 
proportion to that of the other tissues of the body, therefore in the 
adult its weight represents only j-q of that of the entire body. When 
the organ is outlined upon the body surface, liver dulness is found to 
extend from the fifth interspace in the mammary line to about an inch 
below the border of the ribs; in the axillary line it reaches the seventh 
intercostal space ; and posteriorly it extends to the ninth intercostal space. 

In order to examine the liver to the best advantage, the child should 
lie upon its back with the knees flexed to relax the abdominal muscles. 
The lower border may be outlined by percussion, and by light pal- 
pation from below upward using only the finger tips. The upper 
border is easily outlined by percussion, since there is a marked contrast 
between liver dulness and pulmonary resonance. 

In rare instances the liver occupies an abnormal position. It may 
be found on the left side of the body in cases of transposition of the 
viscera; it may be forced downward by right-sided pleural effusion, 
or by contraction of the chest wall from rickets; or its weight may 
stretch and elongate the ligaments which hold it in place, and make 
it sink to a lower level in the abdomen than is normal. This accident 
occurs most commonly in infants and young children who are ill- 
nourished and anemic. 



JAUNDICE, OR ICTERUS 369 

BILE. 

The composition of bile, which is the product of the secretory 
activity of the liver cells, differs slightly in the child from that in the 
adult. It contains a larger quantity of mucin and less of acids. The 
relatively small proportion of acids is largely responsible for the 
difficulty with which an infant digests fats, and accounts in some 
degree for the ease with which fermentation is set up in the intestinal 
canal. The other constituents of bile are fat, organic salts, lecithin, 
cholesterin, and about 97 per cent, of water. 

JAUNDICE, OR ICTERUS. 

Icterus neonatorum, which is usually a physiological phenomenon, is 
the most common form of jaundice in infancy. After the third or 
fourth year acute catarrhal jaundice, which is quite rare during 
infancy, is as common in children as in adults; but other forms of 
jaundice are seldom observed. 

Obstructive Jaundice. — Etiology. — Jaundice is merely a symptom 
of disease. It is a staining of the skin and secretions with pigment 
derived either from the bile or from the blood. In the latter case the 
jaundice is called hematogenous, because of its origin; and when the 
pigment is derived from the bile as a result of obstruction to the flow 
of bile through the bile ducts it is called hepatogenous. Obstructive 
jaundice is another term for the hepatogenous variety, while the 
hematogenous is sometimes called unobstructive jaundice. 

Obstructive jaundice is by far the more common, and may be due 
either to congenital obliteration or stenosis of the bile ducts, to 
impaction of a gall-stone in the common duct, to pressure upon the 
lumen of the bile ducts by enlarged glands or tumors in adjacent 
organs and tissues, or to fecal accumulations within the intestines. 
Wry rarely the bile ducts may be obstructed by an impacted round- 
worm or by hydatid or echinococcic cysts. 

The most common form of obstructive jaundice is the acute catarrhal 
type which arises when the mucous membrane of the bile ducts becomes 
swollen, and obliterates the lumen of the bile passages. This inflam- 
mation of the bile passages is, as a rule, the result of extension -of 
inflammation from the small intestine; but, although it is usually 
associated with gastro-intestinal disturbance, it is now generally 
believed to be of infectious origin, a belief which is supported by the 
occurrence of several epidemics of acute catarrhal jaundice. It is 
sometimes a complication in the acute infections, especially scarlet 
fever and measles. So far bacteriological investigations have failed 
to demonstrate the presence of any specific organism in acute catarrhal 
jaundice, although Jaeger isolated a bacillus of the proteus group 
(proteus fluorescein) in the urine of these patients. 

Symptoms. — The most characteristic sign of jaundice of the obstruc- 
tive type is the yellowish discoloration of the skin caused by the 
24 



370 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

deposition of bile pigments. The skin is also irritated by these pig- 
ments; it itches intensely, and may even present lesions of urticaria 
lichen, or furunculosis. In addition to the discoloration of the skin, 
the sclera has a yellowish tinge, and the urine and perspiration may 
also be stained. The stools, on the other hand, are clay-colored, and 
absolutely devoid of biliary coloring matter, while the tears, saliva, 
and mucus are also free from discoloration. 

In order to test the urine for the presence of bile, put a few drops 
of urine and half as many drops of nitric acid on a porcelain plate, 
and allow them gradually to approach each other and fuse. If bile 
pigment be present a play of colors appears in which red, violet, green, 
and yellow predominate. 

A slow pulse is very characteristic of jaundice in the adult, but is, 
as a rule, not so invariable in children; it is due to the sedative action 
of the bile salts upon the heart mechanism. The principal subjective 
symptoms of the ordinary case of jaundice are vertigo, headache, 
nervous irritability, and depression of spirits which in the child is 
apt to manifest itself as stupidity. 

In acute catarrhal jaundice the foregoing symptoms are usually 
preceded by more or less gastro-intestinal disturbance with nausea, 
vomiting, anorexia, diarrhea or constipation, and pain and tenderness 
in the epigastrium. The liver is generally somewhat enlarged, and 
may be quite tender. There is a rise in temperature to 101° or 102° 
F.; but, aside from a mild feeling of malaise, the child does not espe- 
cially complain, and many of these cases are treated in the out-patient 
dispensaries. 

Severe obstructive jaundice is rare, but may occasionally be met 
with. The involvement of the nervous system is pronounced, and is 
marked by delirium, convulsions, and unconsciousness. There is 
also high fever, and rapid, irregular pulse and respirations. In these 
cases death usually supervenes quickly from exhaustion. Important 
features in jaundice are the tendency to hemorrhage and the lengthened 
coagulation time of the blood, which contraindicate any but the 
most urgent operations on these children. 

Diagnosis. — The diagnosis of jaundice is easy; but the real purpose 
in diagnosis is to discover the cause and the seat of the obstruction. 
The acute catarrhal type may be diagnosed by its mild symptoms 
together with a history of associated gastro-intestinal derangement 
and by excluding, as far as possible, other causes of obstruction of 
the bile ducts. 

Prognosis. — In acute catarrhal, jaundice, unless associated with an 
acute infectious disease, the prognosis is favorable. In jaundice due 
to other causes, the prognosis depends absolutely upon the gravity 
of the causative factor. The course and duration of an attack of 
jaundice also depend largely upon the cause. Ordinary simple catar- 
rhal jaundice runs a course of two to six weeks' duration, but in 
exceptional cases may last much longer. 



JAUNDICE, OR ICTERUS 371 

Treatment. — Unless there is elevation of temperature, the child 
need not remain in bed but should be kept quiet. An initial course of 
calomel should be given, 1 grain in doses of T V of a grain every hour 
to a child under five years of age, and 2 grains in doses of J of a grain 
to the child above five. 

The diet must be carefully regulated, and starches, sugars, and fatty 
foods restricted. Bland and easily digestible articles of food, such as 
broth, skimmed milk, albumen-water, and toast are permissible at 
the onset and, as improvement is noted, lean meat, fish, chicken, and 
vegetables may be allowed. 

The bowels must be kept regular, and for this purpose sodium phos- 
phate, 10 to 20 grains, calomel, \ to J of a grain, or saline mineral 
waters, such as Carlsbad or Vichy, may be given daily. 

Alkaline baths are beneficial, and may easily be prepared simply 
by adding 2 ounces each of sodium bicarbonate and sodium chloride 
to a tub of water. When the itching is distressing, a wash containing 
1 drop of phenol to the ounce may be applied to the skin, and will 
usually relieve it. Fresh air is particularly needful in these cases, and 
the child who is able to play about should be kept out of doors as much 
as possible. 

In severe attacks of jaundice the patient should be put to bed and 
a hot-water bag or mustard plaster applied to the epigastrium to 
relieve the pain. If this does not bring relief paregoric may be 
administered in 5- to 10-drop doses every three hours. To control 
the vomiting, it may occasionally be necessary to give cocaine, -fa to 
yV of a grain, every three hours until the vomiting ceases. In the 
grave types of jaundice the child's strength must be kept up by 
stimulation, and brandy, 10 to 20 drops, and aromatic spirits of 
ammonia, 5 to 10 drops, may be given every two or three hours by 
mouth, as well as camphorated oil, 1 to 3 drops, and strychnine 
sulphate, t^o" to 2Tff of a grain, hypodermically. If there are severe 
hemorrhages, salt solution by slow proctoclysis, and lead acetate, T V 
to | of a grain, or ergot, 1 to 2 grains, should also be given every 
three hours. 

Hematogenic Jaundice. — Hematogenic, or non-obstructive, jaundice, 
which is due to alteration in the state of the blood, may be observed 
during the course of a great number of diseases among which are the 
following: sepsis, typhoid fever, malaria, congestion of the liver from 
cardiac or pulmonary disease, syphilis, tuberculosis, specific fevers, 
acute yellow atrophy of the liver, Winckel's disease, Weil's disease, 
also after severe hemorrhage, in phosphorus and phenol poisoning, 
and in cyclic vomiting. 

Symptoms. — The symptoms of hematogenous jaundice are chiefly 
those of the underlying causative factor. The jaundice is less intense 
than in the obstructive type, and the urine is less bile-stained, although 
the amount of true urinary pigments, especially urobilin, may be very 
much increased. In this type of jaundice the stools are not clay- 
colored. 



372 DISEASES OF THE G ASTRO-INTESTINAL TRACT 

Course and Prognosis. — The duration of hematogenous jaundice is 
usually brief, since many of the conditions which cause it are fatal. 

Treatment. — The treatment of unobstructive jaundice is essentially 
that of the underlying condition. 

CONGESTION OF THE LIVER. 

There are two forms of congestion of the liver — active and passive. 
Active congestion, which is much less grave than the passive type, 
occurs physiologically after each meal, but may be much aggravated 
by overfeeding. This form of congestion may also be associated with 
acute gastro-intestinal disturbances and infectious diseases. Rarely 
are any symptoms referable to the liver except an occasional dull 
ache, or a feeling of fulness in the hepatic region. 

Chronic, or passive, congestion of the liver is much more common 
during childhood than the acute form, and is always due to some 
obstruction to the flow of blood toward or through the heart. Val- 
vular heart disease is the most common cause of passive congestion; 
but it may also be due to pulmonary disease, such as fibroid pneumonia, 
chronic tuberculosis, or fibrosis and adhesions of the pleura. 

Pathology. — If chronic congestion of the liver persists for a long 
period, organic changes take place. The liver becomes reduced in 
size, and on section it has a nutmeg appearance, due to an alternation 
of dark and light tints produced by the unequal distribution of the 
blood within the liver. Its external surface is smooth. 

Symptoms. — In chronic congestion the symptoms are, as a rule, 
mild. There may be slight tenderness in the hepatic region with, in 
some cases, gastro-intestinal disturbance, such as nausea, anorexia, 
and constipation. The liver is at first enlarged and tender; at times 
it may be possible to detect pulsation of the organ. Jaundice is rare; 
ascites occurs late in the course of the disease; the urine is scanty, 
and of high specific gravity. In most cases the spleen also is enlarged. 

Prognosis. — In passive congestion of the liver the prognosis depends 
entirely upon the causative factor and is, as a rule, less favorable than 
when the congestion is active. 

Treatment. — The most important point in the treatment of passive 
congestion of the liver is the relief of the primary disease. Purgation 
and depletion are beneficial in both the active and passive forms, 
and may be effected by the administration of 1 to 3 grains of calomel, 
followed by 1 dram of sodium phosphate, or 2 to 4 drams of magnesium 
sulphate. The diet should be greatly restricted, and until improve- 
ment takes place only liquids allowed. 

The following prescription for a child of five years has been found 
valuable in the after-treatment of these cases: 

]$ — Tinct. nucis vomici f5J 

Acidi nitrici diluti f 3 J 

Aqua q. s. ad. f5iij 

Sig. — Teaspoonful in water three times a day. 



CONGENITAL ACHOLURIC JAUNDICE 373 



ENLARGEMENT OF THE LIVER. 

An enlarged liver is quite a common finding in children, and is met 
with much more frequently than in adult life. Simple enlargement 
is observed in congestion due to pulmonary or cardiac disease, and 
occasionally accompanies the acute infections. The most common 
forms of enlargement are those due to syphilis and rachitis. There 
is also a certain degree of enlargement of the liver in all diseases of 
the blood, especially in the pseudoleukemia of von Jaksch; but in 
these cases enlargement of the spleen is more marked. 

Other maladies which cause increase in the size of the liver are 
hypertrophic cirrhosis, fatty infiltration, hepatic and subphrenic 
abscess, amyloid and hydatid disease, and Still V disease. The asso- 
ciation of enlarged spleen with enlargement of the liver, and vice versa, is 
quite common in children, and in the majority of the forms of enlarged 
liver mentioned above the spleen also is increased in size. 

There are a number of intra-abdominal and thoracic conditions 
which at first may lead the physician to think the liver enlarged, but 
these can be differentiated from hepatic enlargement by careful 
examination. The liver may be displaced downward by a right-sided 
empyema, pleural effusion, or a circumscribed peritoneal effusion 
between the liver and diaphragm; but in these conditions there is 
flatness over and above the upper part of the normal area of liver 
dulness. Tumors of the right kidney or other organs adjacent to the 
liver may by their proximity either displace the liver or cause an 
apparent increase in liver dulness; but upon careful examination a 
line of demarcation between the tumor and the liver can usually be 
made out. 

CONGENITAL ACHOLURIC JAUNDICE. 

This disease, which is also known as familial jaundice and congenital 
family jaundice, is hereditary, -occurring usually in several members 
of a family, and is due to an abnormal state of the blood which is 
believed to be inherited. 

Two forms of familial jaundice are recognized; one type in which 
the jaundice appears at birth or shortly afterward, and another in 
which the affection does not manifest itself until late childhood or 
early adult life. A peculiar feature of the malady is the absence of 
bile in the urine, hence its name acholuric jaundice. Enlargement 
of the spleen and anemia are also characteristic features of familial 
jaundice. 

Etiology. — Heredity is the most important etiological factor, and 
one can usually obtain a history of the disease having been trans- 
mitted through successive generations of the family. Several mem- 
bers of a family may suffer from it at the same time, males and 
females being affected equally. The primary cause is obscure, but it 
is supposed to be a congenital defect in the hemopoietic system which 
produces an abnormal state of the blood. 



374 DISEASES OF THE GASTRO-INTESTINAL TRACT 

Pathology. — Familial jaundice is hematogenic in origin, and is 
believed to be due to a congenital abnormality of the red corpuscles 
which renders them more fragile than they normally are. This leads 
to an excessive degree of hemolysis, and consequent enlargement of 
the spleen owing to increased functional activity, also to the production 
of an excessive amount of bile pigment by the liver. 

Symptoms. — In the majority of cases the jaundice is present at 
birth, but the discoloration of the skin is usually slight, and the other 
symptoms are mild. In some cases the sclera alone shows pigmen- 
tation, but the degree of discoloration may vary greatly from time to 
time in the same patient. In mild cases the jaundice tends to fade 
and disappears within a few weeks. 

As a rule, there are no marked symptoms of illness, although the 
child may occasionally have a slight fever with malaise and so-called 
biliousness. The liver may be slightly increased in size, and the 
spleen is always decidedly enlarged. Although the urine in these 
cases shows no bile pigment, yet the stools are bile-stained, and upon 
examination of the urine an excess of urobilin may be found. 

Changes in the blood vary from anemia so severe that it causes 
death to merely a slight alteration in the blood picture. As a rule, the 
blood changes are most marked in infancy, and when the blood is 
microscopically examined a great reduction in the number of red 
cells is noted; many of them are smaller than normal, and usually 
a few nucleated red cells are present. There is a great reduction in 
hemoglobin and a low color index; but the leukocytes are practically 
unchanged. 

These children may continue to have such attacks all through life, 
but they are less severe after they are grown up, and, as a rule, do not 
affect the general health. 

Diagnosis. — In familial jaundice the diagnosis can be made, as a 
rule, on the history of the disease appearing in more than one member 
of a family, and in successive generations. Absence of bile in the 
urine, and alteration of the blood picture, with very mild subjective 
symptoms, are also characteristic findings which confirm the diagnosis. 

Prognosis. — This is least favorable in very young infants in whom 
the disease is associated with anemia. Older children and adults suffer 
but little; and, although the affection is liable to persist throughout 
life, the attacks occur after longer intervals with increasing age. 

Treatment. — There is no known cure for this disease, but prophylaxis 
may accomplish much in preventing attacks of jaundice in the children 
who have inherited it. The diet should be carefully regulated so as 
to prevent gastro-intestinal disturbance, and the surface of the body 
should be kept warm and never allowed to become chilled. Fowler's 
solution in 1- to 3-drop doses, or tincture of ferric chloride, 2 to 10 
drops, should be administered for the anemic condition of the blood. 
Any measures which help to build up the general health, such as 
moderate outdoor exercise, ample rest, and change of surroundings, 
are beneficial in these cases. 






CONGENITAL OBLITERATION OF THE BILE DUCTS 375 

CONGENITAL OBLITERATION OF THE BILE DUCTS. 

This affection is quite rare, but a number of cases are recorded 
in medical literature. In some instances it has been observed in 
more than one member of a family. 

Etiology. — The disease occurs more frequently in male than in 
female children, and is to a certain extent hereditary. The exact 
cause is unknown; but it is thought to be due to maldevelopment, 
since it is occasionally accompanied by other congenital anomalies. 
It may also be the result of an idiopathic inflammation of the 
bile ducts in early life, or possibly may be due to congenital 
syphilis. 

Pathology. — In these cases the liver shows marked cirrhotic change, 
being hard, and olive green in color from staining by the obstructed 
bile. The gall-bladder may be completely obliterated, or represented 
merely by a small fibrous sac with scarcely any lumen. In some 
cases it contains a little clear mucus; exceptionally, when the common 
duct alone is obstructed, it may be distended. The common bile duct 
and the hepatic ducts are often entirely obliterated, nothing remaining 
but fibrous cords which when opened may or may not disclose a 
narrow lumen. The bile capillaries are dilated and distended with 
bile, which is usually thick and inspissated. 

Microscopic examination of a section of liver tissue shows but 
little change in the liver substance and practically no degeneration of 
the liver cells; but the bile capillaries are irregularly distended and 
choked up with biliary secretion. The spleen is also enlarged, and 
together with the pancreas may show extensive fibrosis. 

Symptoms. — Infants suffering from this condition may appear 
normal at birth, but if jaundice is not present then it usually develops 
in the course of two or three days, and rapidly becomes intense. In 
exceptional cases jaundice may not appear for two or three weeks, 
even though the bile ducts were obliterated at birth. The intensity 
of the jaundice varies; but the pigmentation never leaves the skin, 
and in addition there may be subcutaneous hemorrhages and extrava- 
sations of blood into the mucous membranes., The stools are white 
because of the absence of bile, and may be quite dry and hard. The 
urine is bile-colored, and stains the napkin, but the amount of biliary 
coloring matter varies considerably. 

On examination, the abdomen is often found to be distended, and 
may contain an abnormal amount of peritoneal fluid, although the 
distention is partly due to enlargement of the liver and spleen, which 
may be quite marked. In a number of cases the general health is 
seemingly unaffected; but in the course of a few weeks or months the 
body nutrition begins to fail, exhaustion and emaciation are progres- 
sively worse, and death usually occurs within a year. The majority, 
however, succumb in much less than a year, and death may ensue 
shortly after birth from hemorrhages about the navel, under the skin, 
or from the stomach or intestines. 



376 DISEASES OF THE GASTRO-INTESTINAL TRACT 

Diagnosis. — To the general practitioner the diagnosis is difficult; 
and, unless something strongly suggests the condition it may not be 
recognized. When the disease is suspected the following symptoms 
will point to the diagnosis: intense jaundice of obstructive type, 
coming on within a few days after birth, and associated with hemor- 
rhages into the skin and from the mucous membranes. 

Prognosis. — The outlook is most unfavorable, since the disease can- 
not possibly be influenced by medicine or surgery except in syphilitic 
cases, and here slight improvement may follow antisyphilitic treat- 
ment. 

Treatment. — It is perfectly obvious that no treatment will avail 
when the bile ducts are obliterated, and even surgical intervention 
can be of use only in those cases where there is merely obstruction to 
the flow of bile. Since a few of these, cases appear to be of syphilitic 
origin, mercury may be administered orally in the form of calomel, 
| to i of a grain, or in gray powder, 1 to 3 grains daily; or it may be 
given by inunction, J to 1 dram of mercurial ointment being rubbed 
into the skin every day. Potassium iodide in 1- to 5-grain doses three 
times daily may also be given for its antisyphilitic properties, and 
because it is theoretically supposed to dissolve fibrous tissue, and thus 
widen the lumen of the stenosed ducts. 

Aside from this mode of treatment, nothing can be done but to 
keep up the general health of the child by judicious feeding and other 
hygienic measures. 

STENOSIS OF THE BILE DUCTS. 

Stenosis of the biliary ducts may also occur in children from 
imflammatory changes within the lumen of the ducts, such as might 
be caused by the passage of a large gall-stone. Pressure from without 
may also occlude the biliary tracts. Occasionally stenosis is produced 
by neoplasms of adjacent tissues, by perihepatitis, and by syphilis. 
Most of the symptoms are due to the underlying cause of the stenosis, 
and an accurate diagnosis of the affection is rarely made. 

Treatment. — The treatment depends entirely upon the cause, and 
consists in the removal of the stenosis and the establishment of free 
drainage of the bile. 



ACUTE YELLOW ATROPHY OF THE LIVER. 

This very rare disease is, fortunately, especially uncommon in 
children. It is characterized by fatty degeneration and atrophy of 
the liver accompanied by toxic symptoms, and is almost invariably 
fatal. 

Etiology. — Acute yellow atrophy sometimes accompanies the acute 
infections, notably diphtheria, erysipelas, and typhoid fever; occa- 
sionally it follows chloroform poisoning. It has also been seen in 
association with syphilis, but its true cause is as yet undiscovered. 



ACUTE YELLOW ATROPHY OP THE LIVER 377 

Boys arc more liable to contract the disease than girls; but in adult 
life more women sutler from it than men, owing to the predisposing 

influence of pregnancy. 

Pathology. — Postmortem examination reveals a liver about one-half 
the normal size, reddish in color, its surface presenting a mottled 
appearance, with areas of red, green, gray, and yellow. In consequence 
of the great destruction of liver cells the organ rapidly dwindle- i i 
size, sometimes even in four or five days. The capsule is wrinkled 
and loose, the tissue is soft and flabby, the lobular markings may be 
wholly obliterated. On section the surface is either of a uniform yellow 
color or presents alternate areas of red and yellow. The yellow areas 
represent an earlier stage of the disease; they contain degenerated 
liver cells within which are fat droplets of all sizes. The red areas 
are composed of cellular debris and connective tissue in the meshes 
of which may be found fat drops and biliary coloring matter. 

Pseudo-bile ducts, or canaliculi, and a certain degree of cell infil- 
tration of the interstitial tissue may be observed under the microscope, 
and indicate an attempt at regeneration of the liver cells and begin- 
ning fibrosis. The bile ducts are in a state of catarrhal inflammation. 
Leucin and tyrosin may be found in the interior of the hepatic and 
portal veins. The skin and other viscera are usually deeply bile- 
stained. There may be small hemorrhages in various parts of the 
body. The spleen is enlarged; there are fatty changes in the heart 
muscle and renal epithelium, and an abnormal amount of serum within 
the serous cavities. 

Symptoms. — This disease begins insidiously, and for several days 
there may be merely slight evidences of gastro-intestinal derangement, 
such as anorexia, nausea, vomiting, jaundice, malaise, headache, and 
abdominal distress. The liver is at this period believed to be enlarged; 
but the symptoms are so mild that the cases rarely come under obser- 
vation at this early stage. Following these symptoms, the disease 
suddenly assumes a grave aspect; the jaundice deepens, vomiting 
becomes severe, and there is an increase in abdominal pain. 

Blood may be found in the vomitus or passed in the stool. Sub- 
cutaneous hemorrhages throughout the body may follow slight injuries, 
and there may be bleeding from the gums. The blood picture usually 
shows a moderate leukocytosis (15,000 to 20,000). Cerebral symptoms, 
such as delirium, convulsions, and drowsiness or coma, are not uncom- 
mon. The urine decreases in quantity, is deeply bile-stained, of high 
specific gravity, and contains leucin and tyrosin. The temperature 
is generally a little above normal, but may be subnormal, although 
there is always a sharp rise before death. The decrease in the size of 
the liver is remarkable; in some cases, a few days after the onset of 
the disease, it can no longer be outlined either by percussion or 
palpation. 

Diagnosis. — At the onset of the disease an accurate diagnosis is 
impossible, since there are no characteristic symptoms; but, when 
fully developed, a case of acute yellow atrophy of the liver should 



378 DISEASES OF THE GASTRO-INTESTINAL TRACT 

not be difficult to recognize except because of its rarity. The cardinal 
features upon which the diagnosis should be based are the intense 
jaundice with ecchymoses, slight fever, persistent vomiting, and 
symptoms of cerebral irritation. The diagnosis may sometimes be 
confirmed by physical examination, which reveals a great reduction 
in the size of the liver and enlargement of the spleen. 

Prognosis. — The disease usually ends fatally within a short time, 
and the mortality is so great that reported recoveries may probably 
be attributed to error in diagnosis. The usual duration of the disease 
is from two to three weeks. 

Treatment. — The treatment of acute yellow atrophy of the liver is 
almost purely symptomatic, for little can be done to arrest the progress 
of the disease. At the onset a course of 1 or 2 grains of calomel in 
divided doses should be given, followed by J to 2 drams of magnesium 
sulphate. Rest in bed is, of course, imperative. The diet, while light, 
should contain the maximum of nourishment in order to support the 
child's vitality. In the cases with cerebral symptoms an ice-bag may 
be applied to the head, and headache relieved by the administration 
of phenacetin or antipyrin, 2 to 3 grains. Saline solution, given by 
slow proctoclysis, may possibly diminish toxemia and keep up the 
child's strength. 

CHOLELITHIASIS. 

Gall-stones are extremely rare in children, but may occur at any 
age from infancy to puberty. In the newborn they are usually fatal, 
and even in older infants cause death within a few weeks. Jaundice 
is intense; in infancy it may be the only perceptible symptom; but 
in older children gall-stones give rise to the same symptoms as are 
observed in the adult. 

Diagnosis. — In older children the diagnosis can usually be made 
from the symptoms; but in infants few cases are recognized. 

Treatment. — The treatment is almost wholly surgical, and consists 
iu the operative removal of the stones, which are generally found in 
the common duct. 

ABSCESS OF THE LIVER. 

This affection is extremely rare during childhood. As in the adult, 
abscess of the liver may be either single or multiple, but is always of 
microbic origin. 

Etiology. — Most abscesses in this organ arise from infection in the 
portal area or from suppurative processes elsewhere in the abdomen, 
such as appendicitis or suppuration of the mesenteric glands. Abscess 
formation in the liver may also be due to sepsis, pyemia, peritonitis, 
typhoid fever, traumatism, phlebitis, or tuberculosis, and has been 
known to follow the migration of round worms into the biliary 
passages. Amebic abscess of the liver is rarely seen in children, even 
when amebic dysentery is prevalent. 



SUBPHRENIC ABSCESS 379 

Pathology. — The right lobe of the liver is the most common seat of 
an abscess, although in some cases the whole lobe may form an abscess 
cavity. The liver is usually enlarged; but there may be no visible 
change in its contour if the abscess be deep-seated. The content of 
the abscess is usually pus which may rupture into the right pleural 
cavity, the peritoneum, or the pericardium, and cause death; in 
exceptional cases it may be discharged through the abdominal wall by 
means of a fistulous opening. 

Symptoms. — In abscess of the liver these are usually severe, but in 
rare cases they may be latent. As a rule, there is pain in the hepatic 
region, and the liver is tender. Chills and sweats usually accompany 
the fever which is the most constant feature of the disease, and ranges 
from 103° to 105° F. Jaundice is not invariably present, but occurs 
in about 50 per cent, of the cases, although it is never intense. Vomit- 
ing and diarrhea are not uncommon. In severe cases prostration comes 
on rapidly. 

On physical examination the liver is usually, but not always, found 
to be enlarged. When there is enlargement, it spreads upward in 
the midaxillary and mammary lines, and is due to the pus present and 
to hyperemia and swelling of the hepatic cells. Fluctuation is a late 
symptom, but can generally be demonstrated, and a characteristic 
edematous condition of the skin and abdominal wall over the hepatic- 
region is observed. Pronounced nervous symptoms and nephritis are 
not uncommon in the latter stages of this disease. 

Diagnosis. — Hepatic abscess is extremely difficult to diagnose, espe- 
cially in the early stages. Pain in the hepatic region, and referred to 
the right shoulder, tenderness over the liver, and an intermittent fever 
w T hich is not malarial, are significant diagnostic points; but it may be 
impossible to state positively that there is an abscess unless pus is 
withdrawn by means of an aspirating needle. 

Prognosis. — The prognosis is usually unfavorable, even when a case 
is treated early. Death is due to toxemia and exhaustion. The mor- 
tality in children averages about 75 to 85 per cent. 

Treatment. — The treatment of hepatic abscess is essentially surgical, 
and unless the child is too weak for operation incision and drainage 
should be advised. Operative interference is useless when there are 
multiple suppurating foci within the liver. 

The child's vitality and strength should be supported by a nourish- 
ing diet and the administration of tonics, such as tincture of ferric 
chloride, 2 to 5 drops, or quinine sulphate \ to 1 grain, three times a 
day. Morphine may be necessary for the relief of pain, and can be 
given hypodermically in ^ to -£$ °f a grain dose, according to the age 
of the child. 

SUBPHRENIC ABSCESS. 

Subphrenic abscesses are rare in children, but are occasionally found 
in association with suppurative conditions in the region of the liver. 
The most common site of such an abscess is the space behind the right 



380 DISEASES OF THE GASTRO-INTESTINAL TRACT 

coronary ligament and extending around its right border to the sub- 
hepatic space. Sometimes the pus accumulates either to the right or 
left of the falciform ligament, or in the lesser peritoneal cavity. 

Etiology. — In most cases subphrenic abscess is secondary to appen- 
dicitis; but it may follow the perforation of a gastric or duodenal 
ulcer, traumatism, cholelithiasis, Pott's disease, perinephric abscess, 
empyema, pneumonia, abscess of the liver, spleen, or pancreas, or 
diffuse peritonitis. 

Symptoms. — The symptoms are pain in the right lower chest and 
about the diaphragm and liver, alternating chills, fever, and sweats, 
dyspnea, and cough. Examination of the blood in these cases reveals 
a leukocytosis of 15,000 to 25,000. The abscess cavity may contain 
pus and, in some instances, gas which causes either tympany or flat- 
ness on percussion over this area. 

Diagnosis. — In subphrenic abscess the diagnosis is based upon the 
history of some disorder which might possibly cause an abscess to 
form in the subphrenic region; upon the presence of dulness, pain, 
tenderness, a tumor, and rigidity of the overlying muscles; upon 
thoracic signs and symptoms, e. g., pleural friction or effusion, upward 
displacement of the right lung, and increased dulness over the liver; 
and upon additional general signs and symptoms of suppuration, such 
as fever, chills, sweats, leukocytosis, and progressive wasting. 

Prognosis. — In children the prognosis is very unfavorable, and with- 
out operation practically all of these patients die. Operation is 
attended with such great shock that the mortality-rate where there 
is surgical intervention is over 50 per cent. 

Treatment. — The treatment is essentially surgical, and consists in 
securing free drainage. The incision is usually made through the 
lower chest wall— very rarely through the abdomen. Should this 
mode of treatment be successful, perfect recovery may be expedited 
by administering tonics, such as syrup of the iodide of iron, 10 to 20 
drops, or the elixir of iron, quinine, and strychnine phosphates, 5 to 10 
drops, three times daily; by putting the child on a full nourishing 
diet; and, if living in the city, by sending it away to the country or 
seashore for pure air and change of scene. 

FUNCTIONAL DISORDERS OF THE LIVER. 

Functional disorders of the liver are quite common in children, 
and are usually referred to as "bilious attacks." The exact nature of 
such derangements is unknown; but they are usually accompanied 
by intestinal indigestion, and seem to depend upon a lack or an impov- 
erished quality of the biliary secretion, for the stools are grayish-white 
or clay-colored, and very hard and dry. In some instances a predis- 
position to these attacks seems to be inherited, the father or mother 
also being affected in the same manner. 

Symptoms. — During such a bilious spell symptoms indicative of 
intestinal indigestion appear, such as coated tongue, offensive breath, 



CIRRHOSIS OF THE LIVER 381 

anorexia, nausea, flatulence, and constipation or diarrhea with foul- 
smelling stools. For a day or two preceding the attack the child is 
fretful and peevish, and if old enough complains of not feeling well. 
The characteristic appearance of the stools is caused by incomplete 
absorption in consequence of the lack of bile elements in the intestinal 
tract. The temperature is usually elevated to 1(M)° or 101° F., but 
rarely reaches 103° F. The urine is highly colored and concentrated. 

These children are usually pale and sallow, and during an attack 
may become very weak; but, as a rule, the symptoms subside in a day 
or two, and recovery rapidly ensues. 

Treatment. — Prophylaxis is important. Children who are subject 
to bilious attacks should have their diet carefully regulated and be 
prevented from overeating. Actual treatment consists in stopping 
all food for twelve to twenty-four hours, and giving water freely. 
Cholagogues are very useful, either calomel, podophyllum, or dilute 
nitric acid, the calomel preferably administered in T V to \ of a grain 
doses every hour until 1 or 2 grains have been taken, followed in six 
to eight hours by magnesium sulphate, \ to 1 dram; or, sodium phos- 
phate in 10- to 20-grain doses may be given each morning in hot 
water. The dose of podophyllum is J to § grain, and of dilute nitric 
acid 1 to 2 drops, three times daily. 

When the symptoms have disappeared, the diet may be increased, 
and cereals, broths, junket, and custards allowed until the full diet 
is gradually resumed. The bowels should be regulated by an occasional 
course of calomel followed by a saline laxative. Abdominal massage, 
moderate exercise, and an outdoor life are especially beneficial in these 
cases. 

CIRRHOSIS OF THE LIVER. 

Cirrhosis of the liver is uncommon during childhood, and most 
rare in infancy, the cases increasing in frequency as adult life is 
approached. It is more common in boys than in girls. It is caused 
by an overgrowth of connective tissue at the expense of the func- 
tionating cellular structure of the organ. As a rule, the liver becomes 
much firmer and smaller than normal; but it may be considerably 
enlarged, and in some cases there is no apparent alteration in size. 
Tavo forms are recognizable in children — the atrophic in which the 
liver dwindles in size, and hypertrophic cirrhosis which results in 
enlargement of the organ. 

Etiology. — Syphilis is one of the chief causes of this affection, and 
it is in association with congenital lues that most infantile cases of 
cirrhosis occur. Alcohol, the most common cause of cirrhosis in later 
life, plays but an insignificant role during childhood. 

A cardiotubercular type of cirrhosis has been described in associa- 
tion with polyserositis, but is comparatively unimportant. The 
eruptive fevers may also be mentioned as having in some way a pos- 
sible influence in the production of cirrhosis. In many cases the cause 
of the disease is obscure. 



382 DISEASES OF THE GASTRO-INTESTINAL TRACT 

Pathology. — In atrophic cirrhosis the liver is small, hard, and lobu- 
lated, and has an uneven surface. There is an excess of connective 
tissue in the organ, this being found around the liver lobules, about 
the bile ducts, and dipping down from the capsule into the liver sub- 
stance, causing the capsule to become adherent. In hypertrophic 
cirrhosis the liver is usually enlarged, the fibrous tissue not showing 
the tendency to contract which it does in the atrophic form. There 
is practically no compression of the portal vein; but the biliary 
channels are obstructed, the flow of bile impeded, and this produces 
jaundice. In the majority of cases of cirrhosis of the liver the 
spleen is enlarged and usually shows a certain degree of fibrosis. 

Symptoms. — This disease may remain latent for a considerable 
time, but symptoms of secondary conditions due to cirrhosis usually 
appear quite early. Among these are gas tro-in test inal disturbances 
due to chronic congestion of the gastric mucous membrane, such as 
nausea, anorexia, irregularity of the bowels, and abdominal discomfort. 
Epistaxis, vomiting of blood, and melena also appear as the result of 
congestion of the mucous membranes, but by relieving the engorge- 
ment are rather beneficial than harmful. 

These children are pale and sallow; the veins of the upper abdomen 
and lower thorax are distended and quite prominent; their flesh is 
flabby; there is a steady loss in weight. There may be slight fever 
in the early stages of atrophic cirrhosis, but jaundice appears less 
frequently than would be expected. In many cases abdominal dropsy 
is the first symptom which calls attention to the cirrhotic liver, the 
accumulation of fluid being enormous, and causing marked distention 
of the abdomen, and often distress from mechanical interference with 
the diaphragm. 

Edema of the legs is not so common, but may occur in consequence 
of obstruction from pressure of the ascitic fluid on the veins which 
return the blood from the lower extremities. Physical examination 
reveals a diminished area of liver dulness, and, as a rule, enlargement 
of the spleen. In these cases death is due to exhaustion, and may be 
preceded by drowsiness, delirium, and coma. 

In hypertrophic cirrhosis, jaundice is present at the onset, grows 
deeper as the disease progresses, and is one of the diagnostic features. 
There is no ascites. Both liver and spleen are enlarged. The course 
of the hypertrophic is more rapid than that of the atrophic form of 
cirrhosis, and the children affected usually die within a year or 
eighteen months. 

Diagnosis. — The cardinal features in the diagnosis of atrophic 
cirrhosis are the decrease in the size of the liver and the ascites. In 
hypertrophic cirrhosis the enlargement of the liver and spleen and 
deepening jaundice are significant, but the diagnosis is often most 
difficult and is frequently made only at postmortem. 

Prognosis. — In most cases the prognosis is unfavorable, and there 
is certainly no possibility of curing the disease and restoring the liver 
to normal; but in some instances we may remove the cause of cirrhosis, 



CIRRHOSIS OF THE LIVER 383 

and thus arrest the disease before the liver is too badly damaged to 
functionate properly. In syphilitic cirrhosis the outlook is thus 
made favorable if antisyphilitic treatment be instituted early. 

Treatment. — In all but syphilitic cases the treatment is largely 
symptomatic, since little can be done to restore the organ to its normal 
state. When syphilis is suspected, mercurial inunctions should be 
given, using h to 1 dram of mercurial ointment daily, and rubbing it 
into a different part of the body each day. 

Mercury should also be administered internally in the form of gray 
powder, dose 1 to 3 grains three times a day; or calomel may Ik- given, 
T V to i of a grain three times a day. It is advisable to continue the 
mercurial treatment for at least a year, and potassium iodide should 
be given in addition in 1- to 5-grain doses after meals, gradually 
increasing the dosage to the point of tolerance. 

In cirrhosis from other causes the underlying factor should be 
removed, whenever possible, in order to arrest the progress of the 
disease. 

These children are, as a rule, poorly nourished and in bad health, 
consequently an attempt must be made to build up their general 
constitution by adequate rest, moderate' exercise, plenty of fresh 
air, and frequent bathing. Particular attention should be paid to 
the diet, which must be nourishing but light on account of the con- 
gestion of the gastric and intestinal mucosa. The body must be kept 
warm, and its surface never allowed to become chilled. 

If relief of the gastro-intestinal symptoms is to be expected, the 
gastric congestion must be removed, and this is best accomplished 
by giving the child alkaline mineral waters before meals. Carlsbad 
and Vichy are the best, and act most effectually when taken hot; in 
fact, hot water is of so much value when taken by the tumblerful 
before meals that, in cases where mineral waters cannot be procured 
on account of their cost, plain hot water should be taken instead. 
Saline purgatives are also of service in relieving the congested stomach, 
and sodium phosphate, 10 to 20 grains, or magnesium sulphate, h 
to 2 drams, may be taken each morning in hot water. 

Besides relieving the symptoms due to congestion, these saline 
depletents also carry off ascitic fluid; but it may be necessary to 
give diuretics as well, or even to tap the abdomen if the accumulation 
of fluid becomes so great as to cause mechanical interference with 
the heart action or the diaphragm. The following prescription for 
a diuretic has proven of service: 

1$ — Potassii bitartratis 3^5- 

Syrupi limonis, 

Aqua aa f§j 

Sig. — 3j. every three hours in water. 

If the heart becomes weak and stimulation is needed, strychnine 
sulphate, to-o to -rko, and atropine sulphate, ^io to Tiyo" of a grain, may 
be given by hypodermic; but if the cardiac weakness is due to over- 



384 DISEASES OF THE GASTRO-INTESTINAL TRACT 

action caused by the pressure of the ascitic fluid tapping should be 
resorted to. , 

To tap the abdomen of a child, the little patient should be held 
in a sitting posture until the trocar has penetrated the abdominal 
wall. The fluid should be drained off very slowly, a little being allowed 
to remain. Before plunging in the needle, care should be taken to 
see that the bladder is empty, since this organ has not infrequently 
been punctured while tapping the abdomen. 

In many cases the fluid returns rapidly and tapping is again neces- 
sary. Laparotomy has recently been advocated as a possible means 
of preventing this recurrence of ascitic fluid. 

AMYLOID LIVER. 

Amyloid degeneration, or lardaceous disease, of the liver, although 
quite rare during childhood, sometimes occurs in association with 
amyloid disease of other organs, and is characterized by an infiltra- 
tion of all the tissues of the liver with amyloid material. The infil- 
tration begins in the walls of the smaller arteries, then invades the 
cells and capillaries and, in extreme cases, permeates even the con- 
nective tissue. 

Etiology. — Tuberculosis, syphilis, and rachitis are the diseases 
most often accompanied by lardaceous infiltration. The usual cause 
of amyloid liver, however, is continued suppuration, especially that 
of chronic bone disease, and it is occasionally observed in association 
with tuberculosis of the hip and Pott's disease. Pulmonary tuber- 
culosis does not, as a rule, cause amyloid disease; but other chronic 
suppurative processes in the lung, such as empyema and bronchiectasis, 
are recognized factors in the formation of lardaceous substance. 
Syphilis of the bone, pernicious anemia, leukemia, and the infectious 
diseases are also predisposing causes. 

Pathology. — The amyloid liver is enlarged, hard, firm, and heavier 
than the normal organ. The surface has a waxy appearance, and on 
section the liver tissue resembles the fat of bacon. When examined 
under the microscope, degeneration of the liver cells is apparent, 
which has been caused by deposits of an amyloid substance resembling 
starch granules; occasionally there is also fatty infiltration. 

If a section of the affected liver tissue is painted with a weak solu- 
tion of iodine, it turns to a mahogany-red color, and on adding sul- 
phuric acid the color again changes to violet or blue. When the liver 
is thus affected, deposits of amyloid substance may also be found in 
the spleen and kidneys. 

Symptoms. — In these cases there are no typical symptoms referable 
to the liver aside from the marked enlargement, which can be demon- 
strated by physical examination of the child. An increasing pallor 
of the skin, with edema and puffmess about the eyes, is a constant 
feature, but there is no jaundice. Occasionally gastro-intestinal dis- 
turbances appear, with nausea, vomiting, and diarrhea. The kidneys 



FATTY LIVER 385 

are usually involved to such an extent that the urine is increased in 
amount and contains albumin and hyalin casts. 

In the terminal stages of the disease, ascites and edema may be 
present, and the child become extremely emaciated from progress ive 
wasting. On physical examination both the liver and spleen are 
found to be enlarged. The enlargement of the liver is uniform, the 
edges are rounded, the surface of the organ is smooth. As a rule, there 
is no tenderness. 

Diagnosis. — This is readily made when we find in a child enlarge- 
ment of the liver with a chronic suppurating process elsewhere in the 
body, and when there is accompanying enlargement of the spleen and 
albuminuria, but no jaundice. 

Prognosis. — In children the prognosis of lardaceous disease of the 
liver is, as a rule, unfavorable because of the gravity of the primary 
disease. When it is possible to remove its cause, improvement in so far 
as this is indicated by a cessation of symptoms may occur, but it is 
questionable whether the liver tissue ever returns to normal. 

Treatment. — Aside from the removal of the cause, the treatment 
of lardaceous disease is largely symptomatic. If syphilis is the under- 
lying factor this disease should be treated. In those cases associated 
with chronic suppuration, the suppurative process must be healed, 
if possible. Since the general health of these children is usually poor, 
they should be put upon a light nourishing diet, take moderate exer- 
cise, and have adequate rest and plenty of fresh air. Tonics containing 
iron, such as the syrup of ferrous iodide, dose 5 to 20 drops three times 
a day, may be given; and, if the circulation be poor, also 1 to 3 drops 
of digitalis after meals. 

FATTY LIVER. 

This disease is common during childhood, and is the cause of many 
cases of enlargement of the liver. It may be due either to fatty infil- 
tration or fatty degeneration of the liver cells, which are more or less 
completely converted into fat. When fatty infiltration takes place, 
fat droplets are found within the liver cells which become larger, push 
aside the protoplasm, and cause it to disappear by interfering with 
its nutrition. In fatty degeneration the protoplasm of the liver cell 
disintegrates, the nucleus loses its staining power, and fat droplets 
representing the principal part of the residue fill the cell. Of these two 
conditions fatty infiltration is by far the more common during childhood. 

Etiology. — Fatty infiltration takes place in children who are overfed, 
and who indulge in an excessive amount of sweets and pastry; to a 
certain extent, too, it is present in every case of adiposity. Children 
in cachectic states in which oxidation of fat is interfered with have a 
fatty liver, and this condition is also associated with gastro-intestinal 
indigestion, tuberculosis, rachitis, and wasting diseases. Fatty degen- 
eration of the liver occurs as a result of the action of various toxins 
upon the liver cells, and is seen in phosphorus and chloroform poison- 
ing; in acute infections, such as diphtheria, measles, scarlet fever, 
25 



386 DISEASES OF THE GASTRO-INTESTINAL TRACT 

smallpox, typhoid fever, miliary tuberculosis, acute leukemia, and 
bronchopneumonia; also in acute yellow atrophy of the liver, con- 
genital syphilis, and chronic tuberculosis. 

Pathology. — It has been estimated that more than one-half of all 
the children who come to autopsy have an abnormal deposit of fat 
in the liver. In fatty infiltration the liver is greatly enlarged in all 
its dimensions, is soft, and has a smooth surface. It is lighter in color 
than the normal organ, owing to the presence of fat, and also to 
anemia of the liver. On cross-section fat droplets may be expressed 
from the cut surfaces with ease, and on microscopic examination 
the fat content of the liver cell is readily detected. 

Symptoms. — There are no subjective symptoms of fatty liver, and 
unless revealed by palpation and percussion the condition may not 
be suspected. The area of liver dulness will be found to be increased, 
but not so greatly as in amyloid disease. The edge of the liver can 
usually be palpated, and is smooth and rounded. In the latter stages 
of fatty degeneration the liver becomes much smaller than usual, 
owing to the rapid destruction of liver tissue. 

Prognosis. — In fatty infiltration the prognosis depends on the 
underlying factor, and if the cause can be removed the liver returns 
to normal. Fatty degeneration is usually secondary to some grave 
condition, and generally proves fatal. 

Treatment. — The treatment is for the most part that of the primary 
disease. In fatty infiltration due to overfeeding, it is possible to reduce 
the size of the liver by regulating the diet, for the exclusion of all 
carbohydrates will stop to a great extent the formation and deposi- 
tion of fat. Abdominal massage and an adequate amount of outdoor 
exercise are also beneficial in these cases. 

TUBERCULOSIS OF THE LIVER. 

Tuberculosis of the liver is not uncommon in children affected with 
general tuberculosis, but rarely causes any symptoms except enlarge- 
ment of that organ, which is usually attributed to some other cause. 
Primary lesions in the liver need hardly be considered; but the infec- 
tion may be carried into the blood stream from the lung and reach 
the liver through the hepatic arteries, or may be carried to the portal 
circulation in intestinal tuberculosis. 

It is also possible for tuberculous infection to be conveyed to the 
liver by way of the bile ducts or lymphatics. In some cases in which 
the primary focus is in the lung, pulmonary symptoms may be latent 
until the disease is well established. 

Pathology. — The miliary type of tuberculosis is the most common. 
Here the liver is usually enlarged, yellow in color, its surface studded 
with miliary tubercles, which are also scattered throughout the interior 
of the organ. They are most abundant within the lobules, and show 
a tendency to cluster about the bile ducts. In more advanced stages 
of the disease these tubercles form cyst-like cavities ranging in size 






SYPHILIS OF THE LIVER 387 

from a pin head to a large pea. Large tubercles are more frequently 
found in the liver during childhood than they are in adult life, but 
are extremely rare. 

Diagnosis. — There is little opportunity to diagnose a tuberculous 
liver unless a large tubercle forms close to the surface and gives rise 
to a palpable tumor. Here the treatment is that of tuberculosis else- 
where in the body. Cirrhotic changes are occasionally attributed to 
chronic tuberculosis of the liver, and occur as its sequel. Tuberculosis 
of the bile ducts occurs in association with tuberculous infection of 
the peritoneum and intestines, the cases being relatively more numer- 
ous in children than in adults. It presents no characteristic symptoms, 
and is commonly diagnosed only at autopsy. 

Treatment. — The treatment is that of general tuberculosis. 

SYPHILIS OF THE LIVER. 

Syphilitic infection of the liver is not uncommon. The majority 
of cases occur in children who suffer from congenital lues, although 
syphilis acquired during childhood may also result in syphilitic hepa- 
titis. The acquired form differs from the congenital in its limited 
distribution, the infection being carried, as a rule, by the hepatic 
artery, while in congenital lues the syphilitic virus is transmitted by 
the umbilical veins, and diffused throughout the liver. 

Most cases of syphilis of the liver are observed in newborn or pre- 
mature infants and, at the latest, become apparent during the first 
few weeks of life. Exceptionally, cases are reported in which the 
disease did not manifest itself in the liver until after the fifth or sixth 
year, but these are uncommon. 

Pathology. — In congenital cases, as a rule, the liver is enlarged at 
birth, and has a smooth but pale or mottled surface. It is much 
harder and firmer than the normal organ, and distinctly resists the 
knife when an attempt is made to section it. On section the cut sur- 
face is smooth and shining, and usually reveals many small gray areas, 
commonly called miliary gummata, which represent a diffused cell- 
growth throughout the organ. This diffuse infiltrative form is most 
common; but occasionally there may be scattered, throughout the 
liver, localized gummatous areas of much greater size, resembling the 
adult form of syphilitic hepatitis, although the gummata are usually 
smaller. 

Adhesions also are frequently found about the capsule of the liver; 
occasionally the liver is adherent to adjacent organs or tissues. In 
the diffuse infiltrative form there is observed under the microscope 
a considerable growth of connective-tissue cells at the expense of 
functionating liver tissue. Later on this causes the cirrhotic changes 
not uncommon in syphilitic hepatitis. Enlargement of the spleen is 
also a common finding in syphilis of the liver. 

Symptoms. — The infants affected are often premature or stillborn, 
and the enlarged liver can usually be outlined on examination of the 



388 DISEASES OF THE GASTRO-INTESTINAL TRACT 

abdomen. If the child is alive at birth, the liver may. then be found 
to be enlarged, or it may become larger within the first few weeks of 
life. Moreover, jaundice and the concomitant signs and symptoms of 
syphilis are usually present. 

The nutrition of syphilitic infants is usually below par, and it is 
generally quite easy to feel the firm smooth edge of the enlarged liver, 
and to detect the spleen which is also increased in size. When con- 
genital syphilis does not affect the liver until later childhood, ascites 
is not unusupl, in addition to those symptoms observed in infancy. 

Diagnosis. — In the majority of cases of congenital syphilis the diag- 
nosis is easy. It is based upon enlargement of the liver in a child with 
inherited lues. The Wassermann reaction and the results of mercurial 
treatment may be confirmatory indications, but are scarcely necessary. 

Prognosis. — This depends to a great extent upon the nature of the 
syphilitic process. It is less favorable in the diffuse infiltrative form 
which may go on to cirrhosis than in the gummatous type. From our 
observations it would seem that recovery is to be expected in the 
majority of cases. 

Treatment. — Mercury should be administered from the time the 
diagnosis is first made until all evidence of syphilis has disappeared. 
After this it may be given at frequent intervals for two or three years. 
Inunctions are especially valuable in infants, and 15 to 30 grains of 
mercurial ointment should be rubbed into the skin each day, choosing 
a different area for the inunction from day to day, the abdominal 
wall, axillse, and groins being preferable sites. 

Calomel, in a dose of § to } of a grain, is the best form of mercury 
to give by mouth, although the gray powder is also sometimes given 
in 1- to 3-grain doses. Iodides are also beneficial when combined with 
mercurial treatment, and may be administered as potassium iodide, 
1 to 5 drops of the saturated solution, or 5 to 10 drops of the syrup of 
ferrous iodide. If stomatitis (mercurial) is threatened, a 3 per cent, 
solution of potassium chlorate should be used as a mouth wash. 

A syphilitic infant should be allowed to nurse from its syphilitic 
mother; its general health should be carefully attended to. Older 
children should be put on a full nourishing diet, take plenty of outdoor 
exercise, and have the advantage of all other hygienic measures for 
the improvement of the general health. 

TUMORS OF THE LIVER. 

New growths of the liver are extremely rare in children, but both 
malignant and benign tumors have been observed. Malignant growths 
are generally secondary, the primary focus being, as a rule, in the 
kidney. Both carcinoma and sarcoma are observed, adenocarcinomata 
being the most frequent. 

Symptoms. — Jaundice and enlargement of the liver are the most 
common symptoms. On palpation the surface of the liver feels very 
irregular and uneven, and nodular tumors may be detected. In some 






DISEASES OF THE PANCREAS 389 

cases the tumor attains an enormous size, and may entirely fill the 
abdominal cavity. 

Treatment. — This is of no avail. It consists mainly of attempts to 
relieve the discomfort, and to prolong the life of the patient. Death 
usually occurs in from two to six months. 

The benign tumors of the liver are the adenoma, angioma, myxoma, 
lipoma, and fibroma. They are very rare in children. 

CYSTS OF THE LIVER. 

Three varieties of cyst may be found in the liver; i. e. f simple reten- 
tion cysts caused by obstruction of a small bile duct, congenital cystic 
disease of the liver, and hydatid disease of the liver. 

Hydatid cyst, caused by the invasion of the liver by the embryo 
or larva of the Taenia echinococcus, is quite rare in this country. These 
cysts, if small, produce no symptoms; but as they increase in size 
the liver slowly enlarges, perhaps considerably, and feels heavy and 
uncomfortable. Jaundice may or may not appear, and there is usually 
no ascites. Hydatid fremitus, which is a trembling felt by the finger 
when a superficial cyst is tapped, is characteristic. 

Diagnosis. — The diagnosis may sometimes be made from these 
symptoms, but it may be confirmed by tapping a cyst, and searching 
for the hooklets of the embryo. Unilocular cysts are most common 
in children. 

Treatment. — Aspiration may cause the cyst walls to collapse tem- 
porarily, but the cyst is apt to fill up again with serum; therefore 
laparotomy and removal of the cyst are recommended. In children 
rupture of these cysts is especially liable to occur, spreading their 
contents throughout the peritoneal cavity, and resulting in multiple 
cyst formation within the abdomen. If possible the cyst should be 
removed whole; if this can not be done, the cyst wall should be 
attached to the edge of the incision, and free drainage thus secured. 
All cases in which there is suppuration should also be freely drained. 



DISEASES OF THE PANCREAS. 

The pancreas is rarely diseased during childhood, but both acute 
and chronic pancreatitis are occasionally observed, and tuberculosis 
and syphilis of the pancreas have been reported. 

Acute Pancreatitis. — Acute pancreatitis is most frequently a com- 
plication of mumps, the symptom appearing within a week after the 
onset of the parotitis, and usually subsiding within a week or ten days. 
There is epigastric pain, with vomiting and diarrhea. On palpating 
the abdomen tenderness may be perceptible in the epigastrium. This 
complication of mumps is, as a rule, not serious, and calls for no par- 
ticular treatment. 



390 DISEASES OF THE GASTRO-INTESTINAL TRACT 

Chronic Pancreatitis. — Chronic pancreatitis is, in most instances, 
a result of syphilis, but may be caused by tuberculosis, or accompany 
diabetes mellitus. The symptoms are by no means typical, although 
there is frequently an excess of fat in the stools. 

Tuberculosis of the Pancreas. — Tuberculosis of the pancreas occurs 
less rarely in children than in adults, and is always considered as a 
secondary affection, which has either extended from adjacent lymph 
glands, or been carried to the pancreas in the blood stream from more 
distant parts of the body. It may be either acute or chronic; but the 
symptoms are not at all characteristic, and the diagnosis is rarely 
made. 



CHAPTER XIV. 
DISEASES OF THE RESPIRATORY TRACT. 

ANOMALIES. 

Congenital absence or rudimentary conditions of the nose are 
rarely met with, but it is not uncommon for an infant to be born 
with its nasal passages considerably narrowed or occluded. If the 
latter defect is bilateral, it must be immediately corrected, or sudden 
death from asphyxia may result, since a baby never instinctively 
breathes through its mouth. 

In later life, mouth-breathing is injurious because it interferes with 
Nature's provision for the filtration, warming, and proper moistening 
of the air during its passage through the nasal cavities, consequently 
the delicate structures of the pharynx, the larynx, the trachea, the 
bronchi, and the lungs suffer. 

The narrow nasal passage may be still more contracted and respira- 
tion greatly obstructed by deformity of the turbinated bones, by a 
hypertrophied condition of the mucous membrane covering them, or 
by a deflected septum due to trauma or asymmetrical bony develop- 
ment of the base of the skull or upper maxilla, or to a high V-shaped 
palate. 

Any difficulty in breathing interferes with proper nursing and feed- 
ing, and, no matter from what cause, may lead to faulty thoracic 
development. W. P. Parsons has called attention to the fact that an 
anterior nasal obstruction produces deformity of the maxilla, and a 
posterior obstruction causes depression and widening of the bridge 
of the nose. 



DISEASES OF THE NASOPHARYNX. 



ACUTE RHINITIS. 

This affection, familiarly known as "a cold in the head," is very 
common in nurslings and throughout infancy. The swollen mucous 
membrane more or less completely blocks the nasal passages, while 
the labored breathing induces great fatigue, and interferes with suck- 
ing as well as with sleep. Moreover, the inflammation is liable to 
spread to the conjunctivae, the nasopharynx, the tonsils, and, through 
the patulous opening of the Eustachian tube, to the middle ear. It 



392 DISEASES OF THE RESPIRATORY TRACT 

often gives rise to cough, which is sharp and irritating when the 
pharynx is affected, and croupy when the larynx is involved. By 
extension, the inflammation may produce tracheitis, bronchitis, or 
bronchopneumonia. 

Etiology. — The exciting cause is, no doubt, of bacterial origin, the 
staplrylococcus, pneumococcus, streptococcus, and the influenza 
bacillus having been found in the secretions, as well as the Diplococcus 
intracellular is. 

Infectious diseases, such as measles, scarlet fever, whooping-cough, 
grippe, and influenza are often preceded or accompanied by coryza; the 
latter, even when exceedingly mild, may be diphtheritic. In view of 
these numerous possible inciting causes and in view of the fact that 
many varieties of bacilli may be and are actually found on the healthy 
nasal mucous membrane, it is difficult to point to a specific cause and 
to say definitely which of the microbes are only accidentally present. 
Under normal conditions the healthy nasal mucosa evidently resists 
the infection, and it is only when this natural immunity is reduced or 
destroyed by a depression of the local or the general resistance that 
rhinitis develops. Some factors that lead to such a lowered resistance 
are: exposure to cold and dampness, careless bathing, wet feet, the 
inhalation of irritating fumes or of dry, dust-laden, or superheated 
air, sudden changes in the weather— especially during the spring and 
winter months — and certainly malnutrition, anemia, and a generally 
run-down condition. The specific rhinitis of syphilis and of tuber- 
culosis is closely associated with the symptoms of these diseases and 
is fully discussed under those subjects. 

Symptoms. — The symptoms include the ordinary phenomena of 
mucomembranous inflammations, sneezing as an early symptom, 
swelling, redness, and increased secretion. After a period of stuffiness, 
the nasal discharge becomes profuse and watery, later thicker, muco- 
purulent, or purulent. It is always purulent in the gonococcic, scar- 
latinal, and diphtheritic varieties, and often irritates or erodes the 
nasal openings or the neighboring parts. In older children there is 
slight if any fever, but should the inflammation spread to the pharynx, 
the tonsils, or the middle ear, the temperature is high and continuous. 
The cervical lymph nodes may swell and become painful, with ner- 
vousness, sleeplessness, lassitude, and headache as the usual con- 
comitants. Uncomplicated cases in older children run an uneventful 
course, recovery taking place in three to ^\e days; but in young 
infants the difficult breathing and eventually the cough interfering 
with sleep and nutrition, their naturally weak resistance is still more 
reduced, and the risk of further spread and dangerous complications 
is increased. 

Where there is a purulent or an occasionally blood-tinged discharge 
accompanied by fever, there is great danger of overlooking the possi- 
bility of diphtheria. The disastrous consequences of such an over- 
sight are self-evident. Therefore, as long as a careful bacteriologic 
examination has not demonstrated the absence of the Klebs-Loeffler 



ACUTE RHINITIS 393 

bacillus, the patient should be given the benefit of the doubt and 
should receive a dose of antitoxin. 

Treatment. — Considering the ease with which the infection spreads 
to the bronchi and the lungs of a delicate infant, thorough and early 
treatment seems especially important. Much can be done in the 
way of prophylaxis by providing proper and seasonable clothing — 
neither too much nor too little, a nutritious, easily digested diet, pure 
non-irritating air, and by judicious hardening begun in summer with 
an open-air life and the daily cold sponge. Coddling, the use of chest 
protectors, overheating the room or the bed during the colder season, 
should be avoided, and exposure to infection by contact with persons 
suffering with catarrh or colds carefully guarded against. 

Active treatment in severe cases will naturally depend upon the 
condition of the patient and the character of the attack. As a rule 
children should be kept in the house in well-ventilated rooms, at a 
temperature of 60° to 70° F, A simple cathartic: — castor oil or calomel 
and salts— causes depletion, rids the gastrointestinal canal of the 
swallowed secretion, and prevents auto-intoxication from the bowels. 
Mild diaphoretics, fresh warm air, moistened occasionally with a 
spray, warm drinks of water or lemonade are useful and agreeable to 
the patient. During the early stage, § to ^ of a grain of sodium chloride 
crystals in each nostril relieves congestion by causing a copious dis- 
charge; for older children, we recommend an alkaline spray — saline, 
Dobell's solution, or one containing 1 per cent, of the chloride, bicar- 
bonate, and biborate of sodium combined — to clear away the abnormal 
secretion, to be followed by a simple protective, such as camphor, 
gr. 1, menthol, gr. 1, liq. petrol. § j, applied to the mucous membrane. 
In children under three years this is best done by instilling a few drops 
into each nostril several times a day. Vaseline or any mild ointment 
will protect the lips and nostrils from excoriation. Adrenalin, 1 to 
1000 solution, is recommended where there is much obstruction from 
an acutely congested mucous membrane, but cocain hydrochloride, 
gr. 3, to the ounce, added to any of the above prescriptions will prove 
almost equally efficacious. In severe cases, painting or spraying with 
25 per cent, argyrol after irrigation with warm saline, proves of value 
if done early enough. Generally speaking, little can be done once the 
secretion has become profuse, but should it continue so for any length 
of time, astringents are indicated — a 2 per cent, solution of formalin, 
although painful, often gives very good results. Kyle recommends 
fluidextract hamamelis 1 rluidram, fluidextract hydrastis, | dram, 
water enough to make 2 ounces, as a cleansing solution and an anti- 
septic, a few drops to be instilled into each nostril morning and night. 

A run-down condition, anemia, or malnutrition, predisposes the child 
to infection of any kind and should be treated. Repeated attacks of 
rhinitis may often be traced to carelessness in bathing the infant; 
or they may be caused by the presence of adenoids or of a foreign 
body, which, interfering with nasal drainage, produces a certain amount 
of irritation and congestion. No permanent results can, of course, be 



394 • DISEASES OF THE RESPIRATORY TRACT 

expected unless the cause be removed. The treatment of the snuffles 
of syphilis, the coryza of tuberculosis, hay-fever, diphtheria, measles, 
etc., is discussed under these respective diseases. 

CHRONIC RHINITIS. 

This rather uncommon affection in infants and young children 
is usually spoken of either as hypertrophic or atrophic, depending 
upon the thickness of the nasal mucous membrane. Many observers 
consider the latter to be merely the natural consequence — the retro- 
gressive stage — of the preceding hyperplasia. In fact, the Schn eider ian 
membrane may show patches of both conditions in the same patient. 

Hypertrophic rhinitis is characterized by a cushion-like swelling 
of the mucous membrane lining the nasal cavity, especially of the 
inferior turbinated bones. It rarely follows the acute forms of coryza, 
but accompanies scrofula and chronically enlarged tonsils and adenoids. 
The patients grow better and again worse with every change from 
warm to cold weather. 

Symptoms. — There is usually some mucopurulent inoffensive dis- 
charge which gathers particularly in the inferior meatus and often 
flows backward into the pharynx causing a teasing cough or neces- 
sitating frequent clearing of the throat. Any slight exposure, or the 
onset of the cold season increases the trouble. The nose, alternately 
one or the other side, seems occluded; at all events, the swollen tur- 
binals, together with the usually coexisting adenoids, cause mouth- 
breathing, especially at night. This in turn diminishes the appetite, 
disturbs the sleep, and creates a tendency to catarrh of the pharynx 
and the lower air tubes. A nasal voice, vertigo, migraine, unilateral 
headache, and ear trouble are perhaps the most frequent accompany- 
ing symptoms. 

Treatment. — In addition to what has been said about treatment of 
the acute form, it is necessary to ascertain and remove the cause that 
directly or indirectly is affecting the secretions or the circulation. 
Adenoids or foreign bodies should be removed, and deformities of the 
nasal structure corrected by operation. Among other causative 
factors in children from ten to fifteen years of age are: engorgement 
of the turbinals at puberty, or occasionally mental excitement, sudden 
changes in temperature, automobiling, irritant vapors, and gastro- 
intestinal disturbances. In the scrofulous child the nasal condition 
will improve with the use of tonics, malt, cod-liver oil, iron, and nour- 
ishing food — while mountain or sea air will prove an additional advan- 
tage. The improvement of the general health — and the proper regime 
— often does more for recovery than local remedies, but the latter 
must frequently supplement the former. 

For the very young child it is best to avoid nasal douches and 
inspection, but for older children a cleansing solution may be used 
— Dobell's, half strength — to be followed by a stimulating or astringent 
lotion, according to the special requirements of the case. 






EPISTAXIS 395 



ATROPHIC RHINITIS. 



In atrophic rhinitis, the nasal mucosa is thin and pale, and the 
cylindrical cell lining, especially of the inferior turbinals, undergoes 
retrogressive squamous epithelial proliferation. The air-passages of 
the nose thus become dilated, the secretion diminishes and changes 
its character, and a tenacious, greenish-yellow discharge, liable to 
form crusts, clings to the walls of the nasal cavities, where it decom- 
poses and emits a very strong and peculiar fetor. Fortunately for 
the victim, his sense of smell is usually lost. An accompanying 
chronic, dry pharyngitis frequently adds to the distress of the patient. 

As to the etiology, we lack definite knowledge. It seems certain 
that it is not due to syphilis although a specific microorganism may 
possibly be a causative factor, while some connection with tuber- 
culosis has lately been emphasized. The disease occurs in families, 
preferably in girls, but rarely before the age of ten or twelve years. 

Treatment. — When the mucous membrane is merely atrophied, it 
can be restored to normal, but the outlook is less hopeful when actual 
degeneration has taken place. The general health, especially an 
accompanying anemia, or any indication of scrofulosis, should be 
given prompt treatment. Locally, mild, antiseptic alkaline douches, 
or an oily solution, or cotton tampons saturated with a 3 per cent, 
hydrogen peroxide are useful in removing the crusts and stimulating 
secretion. Gentle massage of the mucous membrane with a cotton- 
tipped probe seems beneficial. 

PURULENT RHINITIS. 

A short time after birth a thick, yellowish pus is occasionally seen 
exuding from both nostrils of a baby whose mother has suffered from 
a purulent vaginal discharge at the time of delivery. Such an infec- 
tion, usually limited to the anterior nasal cavities, can be avoided 
by proper care. Once it has occurred, hydrogen peroxide, 15 vol., 
or a mild alkaline antiseptic, should be used for thorough cleansing 
followed by an astringent lotion applied by atomizer or swab. 

EPISTAXIS. 

Xose-bleeding is rare in very young infants except in cases of sepsis 
or of syphilis. During childhood, however, epistaxis is quite common, 
apparently more so in boys, though girls are likely to suffer from it 
at puberty. The cause is not always obvious, but local and general 
factors together with mere delicacy of the tissues are responsible for 
most of the cases. Local causes include inflammatory changes, the 
presence of foreign bodies, tuberculosis, syphilis, erosions of the septal 
mucous membrane, and, more especially, trauma from falls, blows, 
or picking of the nose. Epistaxis may occur in general infections, 
such as typhoid fever, malaria, measles, influenza, scarlet fever, 



396 DISEASES OF THE RESPIRATORY TRACT 

whooping-cough, and nasal diphtheria; in diseases of the blood, such 
as hemophilia, grave forms of anemia, purpura, and scurvy; and in 
conditions that produce passive congestion, such as valvular heart 
affections, Bright's disease, adenoids, croupous pneumonia. Mental 
or physical excitement, or the slightest injury to the mucous mem- 
brane, may also excite epistaxis. It usually proceeds from a vessel 
in the anterior part of the septum, but occasionally the lesion is near 
the posterior nares. The blood then trickles down the throat, and 
may be either coughed up, arousing a suspicion of hemoptysis, or it 
may pass on into the stomach and be vomited up, or discharged through 
the rectum. 

Treatment. — Any restriction around the neck should at once be 
loosened. Except in case of an underlying constitutional derange- 
ment the nasal hemorrhage will often stop spontaneously without 
treatment. However, cold applications over the nose, the forehead, 
or the nape of the neck can do no harm; while more efficient treat- 
ment consists of outside pressure, digital compression of the facial 
artery, the introduction of dry cotton compresses to the bleeding 
point, or the application of collodion to the bleeding area. Should any 
of these, or a simple astringent — a 5 per cent, solution of zinc and 
copper sulphate and lead acetate — not suffice, a solution of adrenalin, 
1 to 10,000, injected w T ith a soft-rubber syringe, or applied on gauze 
strips over the bleeding point after the removal of the blood-clots, 
will prove effective. For the permanent relief of ulcers or erosions, 
usually found upon the anterior part of the septum, the parts should 
be thoroughly cleansed and dried, and touched once or twice with a 
50 per cent, silver nitrate solution, or a 15 per cent, solution of chromic 
acid. All other means failing, the anterior and posterior nares may be 
packed with cotton, either plain or medicated, with 1 to 1000 adrenalin, 
hydrogen peroxide full strength, or 8 per cent, antipyrin. This pack- 
ing should be applied w T ith a moderate degree of firmness but should 
not be allowed to remain in longer than twenty-four to forty-eight 
hours in order to prevent a possible devitalization of the mucous 
membrane. Tincture of ergot and calcium lactate may be given but 
they are usually not very efficacious. 

ADENOIDS. 

Childhood, especially between the fourth and eighth years, is charac- 
terized by a peculiar liability to excessive development of lymphoid 
tissue, chiefly at the upper crossing of the respiratory and alimentary 
passages. There it forms the so-called "ring of Waldeyer," which in 
as many as 75 per cent, of all children who live in moist climates or 
near the seashore is prone to increase to tumor-like formations in 
three places — the pharyngeal and the two faucial tonsils. The fourth 
or lingual tonsil does not, as a rule, develop before puberty. The 
adenoid, also called Luschka's or the pharyngeal tonsil, is a reticular 
structure filled with lymph cells rich in bloodvessels, covered by 



ADENOIDS :'> ( J7 

several layers of columnar epithelium, and differing from the faueial 
tonsils by the absence of follicles. It may be enlarged at any age, 
even in nurslings, especially in idiots; it is soft and friable in infants, 
and hard or fibrous in older children and adults. While the impor- 
tance of this diseased condition in children is generally recognized, 
it does not seem to be sufficiently appreciated in infants, at least so 
far as efficient treatment is concerned. In some instances, no doubt, 
it is not merely a local condition, but coexists with congenital syphilis 
or a tuberculous constitution and gives rise to symptoms similar to 
those of syphilitic coryza; in fact, enlarged adenoid growth is, perhaps, 
the chief cause of chronic snuffles. 

It is somewhat astonishing to find that a purely local condition 
may produce so many symptoms; their severity, of course, depends 
largely upon the size of the adenoid and the presence or absence of 
complicating inflammatory processes. That these symptoms need 
not necessarily be present in each individual case, and that the clinical 
picture of adenoids in a child of six to eight years differs considerably 
from that of the baby, is self-evident. It may not be superfluous, 
however, to point out the fallacy of believing an infant has no adenoids 
because it keeps its mouth closed. If we bear in mind that at birth 
the posterior choana are just large enough to admit a medium-sized 
male catheter, and that the nasopharynx is very shallow indeed, \ 
to \ of an inch, we can readily see how even an apparently small 
adenoid growth may considerably constrict or practically obstruct 
the nasal passages. Such interference with normal breathing leads 
to all forms of disturbances, already discussed under the subject of 
rhinitis, and gives rise to chronic snuffles, often to mouth-breathing, 
especially at night, and its sequehe — difficulty in feeding, dryness of 
the mouth, the habit of snoring, so distorting to the features, and a 
constant tendency to cold in the head. Sleep is interrupted and unre- 
freshing because the little one continually tosses about seeking to 
find a position in which he may be able to breathe more freely, and 
because an irritating cough usually appears upon lying down. Attacks 
of pavor nocturnus are common; excited, no doubt, by the respiratory 
difficulty. Anyone who has been compelled to sleep for a night with 
his mouth open does not easily forget the feeling of exhaustion, the 
bad taste, and the want of appetite experienced on awakening, and 
will readily understand why such children have no relish for breakfast. 
Unable to masticate for any greater length of time than the period 
during which they can hold their breath, they eat only enough to 
satisfy the acute pangs of hunger and naturally bolt their food; 
through impeded respiration they inhale an amount of oxygen quite 
insufficient for intensive metabolism, and they get their sleep only 
by snatches. It is not astonishing then that the general nutrition 
suffers, with a consequent reduction in the power of resistance. This, 
in addition to a more or less pronounced catarrh of the nose, the naso- 
pharynx, the tonsils, and the Eustachian tubes, accounts for the 
increased liability of these children to all forms of tonsillitis, to rheu- 



398 DISEASES OF THE RESPIRATORY TRACT 

matism, tuberculosis, scarlet fever, diphtheria, measles, etc., and the 
greater severity of their symptoms if attacked by any of these diseases. 

The speech is peculiarly thick. In exceptional cases stuttering and 
stammering are reported to have been cured by adenectomy. The 
hearing also is often impaired; for the narrowing or obstruction of 
the Eustachian tube interferes with the proper ventilation of the 
middle ear, and thus causes retraction of the drum-head. Other 
disorders observed are those of taste and smell, irregular dental devel- 
opment, a high palatal arch, flat chest, diminished lung expansion, 
and, where there is a tendency to rickets, deformities of the bony 
thorax. While there is as yet no positive proof that adenoids cause 
asthma, chorea, or epilepsy, except in the presence of inherited neuro- 
pathic tendencies, yet it is a fact that enuresis has in some cases been 
cured by the removal of large adenoid vegetations. J. R. Clemens 
has recently pointed out that children with hypertrophied tonsils and 
adenoids show excessive general perspiration while asleep, but not 
during their waking hours. This abnormal sweating might well be 
mistaken for an early symptom of rickets were it not that it disap- 
pears after surgical removal of the excessive lymphatic growth. 

Aprosexia, indifference to and diminished capacity for mental 
work, especially noticeable in school children with adenoid disease, 
is no doubt partly due to defective hearing which arises from the 
rarefaction of the air in the middle ear; there is, however, a probability 
that enlarged adenoids pressing upon the posterior and lateral walls 
of the nasal pharynx interfere with the return flow of lymph or blood 
from the brain, and cause mental disturbance by reflex action. Chil- 
dren with enlarged adenoids often run a slight temperature for days 
at a time, and, as already stated, a stubborn mucopurulent rhinitis 
is a common complaint in such cases. The discharge becomes more 
or less blocked up in the nose forming a favorable nidus for bacteria, 
and the resulting inflammation manifests itself by enlargement of 
the cervical lymph nodes and glands. The infection may reach the 
middle ear through the Eustachian tube and produce an otitis media; 
it may also spread downward and involve the pharynx, the. larynx, 
the bronchi, and the lungs. A tenacious secretion collecting in the 
pharynx may be the cause of a spasmodic cough, retching, or vomit- 
ing, and may simulate either bronchitis or the early stage of whooping- 
cough. Many a long-standing case of so-called bronchitis disappears 
as if by magic on the surgical removal of previously unsuspected 
adenoids. 

Treatment. — The lymphoid tissue is most labile and, in mild cases, 
the enlargement may possibly disappear under judicious topical 
applications of iodin and glycerin combined with treatment of the 
coexisting rhinitis, respiratory gymnastics, and last, but not least, 
a rational diet appropriate to the age and the digestive capacity of 
the patient. Large adenoids, however, which cause pronounced symp- 
toms, cannot be thus melted away, and no time should be lost in resort- 
ing to the necessary surgical measures. 



ADENOIDS 399 

When should an operation be undertaken? As soon as the condition 
causes any noteworthy symptoms. With an infant it may be wise 
to wait until the fifth or sixth month of life. To delay longer simply 
because the adenoid vegetations may recur does not seem justifiable, 
especially in view of their deleterious influence upon development 
during this period of very active growth. Xo definite rule, however, 
can be laid down for cases in which the hypertrophy is only slight and 
the symptoms apparently absent; we say apparently, because close 
observation often reveals manifestations which had escaped attention 
before. 

If spring or early summer can be chosen for the operation, the patient 
will have more time in which to recuperate before the onset of cold 
weather. The long-standing cases operated upon late in the fall 
may again exhibit the old susceptibility to colds during the winter 
that follows. While an acute inflammation, of course, necessitates 
a postponement of operative interference, this need not be delayed 
on account of a slight rise in temperature — 100° to 101° F. — if it is 
due to the presence of the adenoid itself. In fact, this temperature 
usually disappears after the operation. Perhaps no operation i- so 
often inefficiently done. Whenever possible, it should be left to the 
skilled hands of the specialist. 

As a rule, after two years of age, the hyperplasia involves all the 
tonsils, pharyngeal as well as faucial; these should, therefore, not be 
treated as separate conditions. About 75 per cent, of all children above 
two years of age that have enlarged adenoids also have enlarged tonsils. 
The essential point is complete extirpation, though the details of the 
procedure itself may vary. 

Since infants and weakly children cannot well endure hemorrhage, 
and since chronic cases are liable to bleed profusely, some practitioners 
give calcium lactate or chloride in 10-grain doses for two days prior 
to operation, the last dose being given on the morning of the operation. 
It is a safe principle to give a cathartic the night before and, of course, 
to withhold all food on the day of the operation, which should be 
performed in the early morning if possible. Infants under one year 
of age require no anesthetic for adenectomy. There is very little 
shock, and the whole procedure is over before the babe has had time 
to be seriously frightened. An assistant, holding the little patient 
with its arms alongside the body securely wrapped in a sheet, presses 
his right hand against its arm and his left hand against its forehead 
in such a way as to incline the head against his left shoulder. Per- 
haps a better plan is to have a nurse seated with the child on her 
lap, with its arms crossed and firmly held. An assistant standing back 
of the chair steadies the infant's head between his hands and at the 
same time keeps the mouth gag in place. The operator then presses 
down the tongue, passes the chosen instrument (a Gottstein or a 
Kirstein curette, or a Shutz adenectome) behind the soft palate, 
brings the blade forward as far as possible, and then, by making a 
stroke at first backward and then downward, removes the adenoid 



400 DISEASES OF THE RESPIRATORY TRACT 

in one piece. Any remaining particles can be quickly cleared out 
with the forceps. The patient's head is then held forward over a 
basin during the profuse bleeding which usually follows but which 
lasts only a few minutes. If the hemorrhage is severe, it can easily 
be checked by hot or cold water locally applied, or by any form of 
cold application to the face. The child is put to bed on its side with- 
out a pillow, and should be carefully watched for one or two nights 
by a nurse, with instructions to use a 1 to 5000 adrenalin chloride solu- 
tion as a spray in case of secondary hemorrhage. 



DISEASES OF THE LARYNX. 



ACUTE LARYNGITIS (FALSE CROUP— SPASMODIC CROUP). 

Acute laryngitis, an inflammation of the laryngeal mucous mem- 
brane, is also popularly known as false croup, or spasmodic croup, 
because in young children of a certain predisposition it is often asso- 
ciated with spasm of the glottis which gives rise to alarming symptoms. 
When associated with the acute infectious diseases, especially measles, 
acute laryngitis may become very serious. The occurrence of false 
croup with influenza, whooping-cough, and scarlet fever, is discussed 
under these respective headings. Acute laryngitis proper is nearly 
always of microbic origin. While it may appear as a primary disease, 
it is usually secondary to an infection spreading downward from the 
upper respiratory passages, such as rhinitis, tonsillitis, or catarrh 
of the nasal pharynx; in rare instances the pathological process may 
extend upward from the bronchi and the trachea. It is a well-known 
fact that bacteria capable of producing inflammation are found on 
the normal mucous membrane, which has the power to destroy them. 
Their pathogenicity may be due either to an enormous increase in 
numbers, or to a lowered local resistance, the result of congestion 
from one cause or another, or to an impaired general condition due to 
some chronic ailment. Children under six years of age suffering from 
rickets, anemia, malnutrition, chronically enlarged tonsils and 
adenoids, or those having an acquired or an inherited spasmophilia, 
are particularly liable to have serious as well as frequent attacks of 
laryngitis associated with spasm of the glottis, one attack apparently 
creating a tendency to another. In children without this predisposi- 
tion or in those over six years of age, the disease is comparatively mild 
in type and devoid of spasmodic manifestations. 

Pathology.^-The mucous membrane of the larynx, and often to a 
slighter degree that of the trachea also, shows localized or general 
hyperemia and a swelling, which seems limited to the mucosa in a 
mild case, but which may involve the submucosa in the more severe 
one. There is, however, very little tendency to edema in children as 



ACUTE LARYNGITIS 401 

compared with adults. The initial dryness is soon followed by an 
increased secretion of mucus which, clinging to the swollen mucosa, 
still further narrows the lumen of the windpipe, and interferes with the 
free passage of air. This at times produces a marked stenosis which 
may become almost complete, causing a spasm of the laryngeal 
muscles, especially of the adductors. 

Symptoms. — In older children the ordinary case lasts from four to 
ten days. It is commonly preceded by nasal or pharyngeal catarrh. 
or it may be associated with influenza, measles, or typhoid. The 
clinical picture of simple infantile laryngitis closely resembles the 
adult type, except that the cough is more croupy and the dyspnea 
more marked. All the symptoms — slight fever, cough, dyspnea, and 
hoarseness — become more pronounced at night. Usually there is 
pain and tenderness over the larynx. Alarming symptoms are seen 
principally in infants and young children, for even a moderate swelling 
of the laryngeal mucous membrane in a very young child interferes 
with inspiration and may readily cause an obstruction, especially if 
there is a tendency to spasms, so usual in infants. In mild cases the 
hoarseness, the cough, and a high temperature, 100° to 103° F., 
may continue for a few days, and then pass on" without more severe 
manifestations, but other and more alarming symptoms frequently 
make their appearance. After having played around all day apparently 
well except, perhaps, for a slight coryza, the child toward evening 
develops a slight hoarseness and a barking cough, which so increase 
in severity and frequency that sleep becomes restless. There is no 
evidence of serious illness, the temperature rise being only slightly 
above the normal, but respiration gradually becomes increasingly 
difficult, until suddenly the child awakens terrified, sits up, apparently 
suffocating, and struggles for breath. The aire nasi vibrate rapidly, 
all the accessory respiratory muscles are brought into play, the lips 
and the finger tips become livid, and the labored breathing with its 
loud inspiratory stridor is only interrupted by a loud, ringing, metallic 
cough, which is sometimes hoarse and harsh. The distress may last 
from a few minutes to one-half or a full hour, often longer, but in a 
somewhat milder form, until finally the little patient falls back 
exhausted to continue his interrupted sleep. When he awakes the 
next morning the dyspnea has completely disappeared, and he is 
apparently as bright and well as ever except for a hoarse voice and 
some cough. However, unless adequate treatment is given, the cough, 
the hoarseness, and the dyspnea are liable to return at nightfall and 
to culminate in a second attack, perhaps even more severe than the 
first one. Usually these symptoms do not. recur more than three 
nights in succession, but after exposure or other indiscretions some 
children suffer from slight laryngeal spasms every few weeks during 
the cold season. 

Treatment.— Even mild cases must be treated with care on account 
of the possible development of spasms or of edema. The child should 
be purged with calomel given in divided doses, and should be put to 
26 



402 DISEASES OF THE RESPIRATORY TRACT 

bed in a warm (70° F.), well-ventilated room. Inhalations of steam, 
plain, or medicated with tincture of benzoin comp., oil of eucalyptus 
or creosote, repeated in severe cases every two hours for fifteen 
minutes, are very soothing to the inflamed mucous membrane. If 
the adjacent structures, the faucial or lingual tonsils, or the naso- 
pharynx are inflamed they must be energetically treated. Hot drinks, 
lemonade, but better still milk with lime-water, help to start the 
secretion; when the latter grows profuse, expectorants are indicated. 

A teaspoonful of the syrup or the wine of ipecac relieves the spasm 
and the cough for a time by causing vomiting of the accumulated 
secretions, but such medication cannot be advised for weakened chil- 
dren. In some cases antipyrin in small doses — 1 grain for a child 
of tw r o years — every two hours, may be necessary for relieving the 
spasm, and syrup of ipecac and squills, of each 5 drops, for soothing 
the irritating cough, while some exceptional cases may require heroin, 
to grain, or Dover's powders in small doses. 

When in connection with the dyspnea, the stridor, and the respira- 
tory recession, there is marked frequency of respiration with extreme 
lividity or pallor and prostration, it may become necessary, especially 
in a very young child, to perform intubation or even tracheotomy. 
It goes without saying that a good prophylactic dose of diphtheria 
antitoxin should be given in every doubtful 'case. During convales- 
cence little treatment will be required beyond the use of the syrup of 
hydriodic acid and ferrous oxide as a tonic, and protecting the child 
against exposure. 

Prophylaxis. — Proper clothing, an out-of-door life, a daily cold sponge 
followed by brisk friction, a simple nourishing diet supplemented by 
tonics — malt extract and cod-liver oil — these together with an annual 
stay at the seashore or the mountains, when possible, will go far to 
prevent the recurrence of croup; the predisposed child, however, 
must not be subjected to extreme changes of temperature, or to expo- 
sure to wet, and should be kept from contact with persons suffering 
from colds. 



EDEMA OF THE LARYNX (GLOTTIS) AND THE SUB- 
MUCOUS MEMBRANE. 

These conditions, both of them rare, may represent either a serous 
infiltration or an inflammatory edema of the larynx. 

Serous Infiltration. — A true infiltration of the submucous cellular 
tissues of the larynx occasionally occurs in chronic nephritis; in fact 
it may be one of the earliest symptoms of the disease. Other etio- 
logical factors may be glands or tumors which interfere with the 
normal laryngeal circulation, cardiac insufficiency, and local irritation, 
such as is produced by inhaling hot or irritating vapors, and by acci- 
dental swallowing of corrosive liquids. In rare cases, the adminis- 
tration of potassium iodide has been known to produce a sudden edema, 
which disappeared readily when the drug was discontinued. 



EDEMA OF THE LARYNX 403 

Inflammatory Edema. — Inflammatory edema, the result of a local 
inflammatory process, is more common. This is a true submucous 
laryngitis, which may be caused by direct infection, by trauma of 
the mucous membrane, by ulcers, impacted foreign bodies, or by an 
infection spreading from the surrounding tissues; it also occurs as a 
rare complication in syphilis, typhoid fever, smallpox, chicken-pox, 
scarlet fever, and diphtheria. The edema usually affects the epiglottis 
and the aryepiglottic folds, but it rarely attacks the vocal cords and 
interarytenoid folds; when associated with constitutional diseases, 
the swelling is apt to be bilateral. 

Symptoms. — While expiration may be quite easy, inspiratory dysp- 
nea is the most striking symptom of edema of the glottis. When 
the aryepiglottic folds are chiefly involved, the laryngeal orifice may 
become practically closed, producing most alarming dyspnea and 
signs of suffocation. Edema of the other parts of the larynx is not 
likely to embarrass the respiration to the same extent. The sudden- 
ness of the onset depends greatly upon the exciting cause, but. as a 
rule, the distressing symptoms develop with great rapidity and may 
prove fatal within a few hours. To this clinical picture may be added 
pain, cough, hoarseness, and dysphagia, if the condition is of inflam- 
matory origin; and, naturally, also all the symptoms of a coexisting 
primary disease. 

Diagnosis. — The examining finger, duly protected, detects a swell- 
ing around the base of the tongue and a more or less pronounced 
tumefaction at either side of it. When the tongue is drawn forward 
during inspection, or, better, when the laryngeal mirror is introduced, 
tumors are seen close together near the root of the tongue, their whitish 
color indicating a serous origin, or, if reddish, an inflammatory origin; 
in the latter case there is also tenderness over the larynx and the 
trachea. Careful examination of the heart and of the urine should 
never be omitted unless the history and the accompanying signs and 
symptoms leave no doubt as to the true cause of the condition. 

Prognosis. — Prognosis depends upon the patient's general condition, 
the underlying cause, and the promptness with which the dyspnea 
can be relieved by medical means, or, in severe cases, by surgical 
measures. 

Treatment. — While the ultimate success depends upon ascertaining 
the etiological factor and treating it effectively, local treatment at the 
time of the attack is of paramount importance. When there is no 
danger of suffocation, cold compresses, externally, and ice by mouth 
are useful. Topical applications of adrenalin may also be tried. In 
the inflammatory form leeches over the larynx, multiple punctures 
of the edematous tissues, deep incision where an abscess is suspected, 
each has its advocates. When the dyspnea is extreme, Heubner 
recommends intubation, followed, if necessary, by tracheotomy and 
subsequent local treatment. At all events, one should be prepared 
to perform tracheotomy if suffocation seems imminent. 



404 DISEASES OF THE RESPIRATORY TRACT 

LARYNGISMUS STRIDULUS (CHILD-CROWING). 

This disease, peculiar to infancy and comparatively rare except in 
foundling institutions, is no doubt a neurosis, causing an incoordina- 
tion of the laryngeal muscles. 

Etiology. — The majority of cases occur chiefly in male infants from 
six to eighteen months of age, and usually during the winter months, 
when babies are more or less closely confined to overheated rooms. 
In children suffering from rickets, tetany, hereditary syphilis, or 
other diseases that produce profound malnutrition and excessive 
excitability of the nervous system, attacks of laryngismus stridulus 
are easily induced by nervous excitement, or by almost any kind of 
peripheral stimulation. A breath of cold air blowing across the sen- 
sitive skin of such a delicate neurotic child, or the reflex action of 
certain nasal conditions, or enlarged cervical or bronchial glands, the 
acute inflammation of adenoids and tonsils, postnasal dropping of 
mucus into the larynx, a tickling of the throat, or some gastric dis- 
turbance, as well as fits of temper, of fright, and of crying are sufficient 
to cause a spasm of the respiratory muscles, especially of the laryngeal 
abductors, resulting in sudden closure of the glottis and the partial 
or complete shutting off of air from the lungs. 

Symptoms. — While the affection when mild may pass unnoticed in 
the beginning, on the other hand, the very first attack may awaken 
the child from its sleep and startle the family by its suddenness and 
severity, the latter depending almost entirely upon the degree of 
spasm. Just before the glottis closes the inrush ing air makes a peculiar 
noise which frightens the child and causes it to struggle for breath; 
its chest remains fixed and its body stiffens, while the epigastrium 
bulges and feels as hard as a board. Respiration ceases, although the 
diaphragm appears to move convulsively, the face turns first pale, 
then livid. With its head thrown back and its eyeballs rolling, the 
life of the little patient seems to be in imminent danger. After some 
anxious moments, a sudden deep inspiration, usually but not always 
accompanied by a crowing sound, shows that the spasm is broken, 
and the danger past. The child breathes rapidly, its terror dissolves 
in tears, and after fretting and crying a little, it finally falls asleep, 
and on awaking seems as well as ever. 

Although these attacks usually come on at night, and awaken the 
child out of a deep sleep, they may appear at any time, and may be 
repeated two or three times a day; in severe cases even as many as 
twelve attacks have occurred in twenty-four hours. The mild 
seizures pass off in ten to twenty-five seconds, leaving apparently 
no ill effects; but the more severe ones may be followed by gen- 
eral convulsions, loss of consciousness, and may even terminate 
fatally. 

Carpopedal spasm is observed in about 50 per cent, of all cases, and, 
when present, becomes intensified during the attack. Laryngismus 
stridulus may last for a few days or for several months, recovery being 



LARYNGISMUS STRIDULUS 405 

heralded by a gradual decline in the severity and the number of the 
paroxysms until they finally cease entirely. 

Diagnosis. — The differential diagnosis is easy if the clinical picture 
and the history are kept in mind, especially the fact that the patient 
is comfortable during the intervals. In laryngismus stridulus a period 
of apnea precedes the crowing inspiration, while the whoop of pertussis 
immediately follows a series of short expirations. Catarrhal laryngeal 
spasm is always associated with symptoms of acute laryngitis; con- 
genital laryngeal stridor dates from birth; in diphtheritic croup the 
dyspnea is lasting and increases in severity; spells of so-called "hold- 
ing of the breath" are usually brought on by anger. 

Prognosis. — The prognosis is good when the underlying cause can 
be treated successfully, and also favorable as far as the attack itself 
is concerned; although weak infants are known to have died from 
asphyxia or from subsequent convulsions. 

Treatment. — During an attack the primary object is, of course, to 
break the spasm and to produce an inspiration. For this purpose, 
inverting the patient and lightly slapping him on the back often 
proves as effective as it is simple. Dashing cold water on the face 
and the chest, tickling the fauces, alternate hot and cold baths in 
rapid succession, a hot sponge over the larynx, or a whiff of chloroform 
administered by a competent person, have all been found useful. 
But, if these means should fail to give prompt relief, intubation or 
tracheotomy becomes necessary. 

Following the paroxysm the child should be kept under the influence 
of chloral for twenty-four hours, and for a week or two sodium bromide 
should be given, 5 grains three times a day in cinnamon water. Con- 
sidering that many of these cases suffer from disturbances of nutrition, 
antipyrin, 1 grain, may be given every four hours to a child one year 
old; antipyrin does not disturb the digestion as do the bromides, unless 
the bromides are given by rectum. The infant must be kept from all 
excitement, such as loud talking, the noisy play of other children, as well 
as the devoted attentions of relatives and friends. Of course, the under- 
lying malnutrition, rickets, tetany, syphillis, tuberculosis, or the disease 
of the nose or throat should be treated in the most effectual way. 

Congenital Laryngeal Stridor. — This is an inspiratory stridor 
peculiar to infants, but of rare occurrence, usually noticed very shortly 
after birth and disappearing spontaneously during the second year. 
Hutchinson calls the condition "a stammer of respiration." It may 
be due to incoordination of the laryngeal muscles or it may represent 
a neurosis like laryngismus stridulus. Some writers suggest a mal- 
formation of the larynx or, rather, a peculiar folding of the epiglottis 
upon itself along the median line and a flabbiness of the false vocal 
cords, which allow the larynx to fall upon itself on inspiration, thus 
producing a valve-like action. 

Etiology. — As regards the etiology, we know little beyond the fact 
that the affection is congenital and that it may be increased by excite- 
ment as well as by exposure to cold. 



406 DISEASES Oh" THE RESPIRATORY TRACT 

Symptoms. — While expiration to all appearances is easy and noise- 
less, an inspiratory stridor in the form of a curious slight crowing 
or purring in the throat is heard. This sound varies in intensity and 
may at times cease altogether; it is rarely audible during sleep, but 
is apt to be louder when the child becomes excited. The voice remains 
unaffected, and, in spite of a slight cyanosis which accompanies the 
dyspnea, the child does not seem uncomfortable. The paroxysms of 
dyspnea usually increase in severity during the first few' months of 
life and gradually subside in the course of the second year. 

Diagnosis. — The disorder is readily differentiated from laryngeal 
spasm associated with enlarged adenoids, laryngismus stridulus, thymic 
asthma, papilloma and edema of the larynx, by its history, its onset 
immediately after birth, by its characteristic respiration accompanied 
by inspiratory dyspnea, and by the fact that the patient is not uncom- 
fortable and the voice remains unaffected. 

Prognosis. — Prognosis is good unless complicated by bronchopneu- 
monia. 

Treatment. — The condition has a tendency to disappear spon- 
taneously, and therefore requires no special treatment; but the child 
should be protected from nervous excitement and undue exposure, 
especially to diseases of the respiratory tract; In infants these have 
a decided tendency to spread to the larynx and the bronchi; in such 
cases every preparation for performing tracheotomy or intubation 
should be made in time. Pure air, sunshine, careful feeding, and the 
usual hygienic measures for improving the general condition will help 
to shorten the course and to modify the severity of the disease. 

NEW GROWTHS OF THE LARYNX. 

Laryngeal tumors rarely occur in children and only exceptionally 
are they malignant. Of the benign growths, papillomata represent 
the most common variety; fibromata and myxomata are too rare to 
require consideration. Papillomata are probably congenital in about 
25 per cent, of all cases, the majority of them making their appearance 
from the first to the fourth year, sometimes developing rapidly after 
laryngeal catarrh. Boys seem to be more frequently affected than 
girls. The growths, usually situated on the vocal cords or within them, 
may be single or multiple, sessile or pedunculated, and sometimes may 
attain the size of a large raspberry. 

Symptoms. — The symptoms naturally depend to a certain extent 
upon the size and the location of the tumor, but they usually resemble 
those of chronic laryngitis. A change of voice, a gradually increasing 
hoarseness and occasional paroxysms of coughing are the early mani- 
festations which may, indeed, date from birth, but which more infre- 
quently appear during infancy and are progressive instead of passing 
off as in ordinary laryngitis. The increasing size of the growth even- 
tually causes a certain degree of obstruction, the breathing becomes 
somewhat difficult, perhaps at first more noticeable during sleep, but 



FOREIGN BODIES IN THE LARYNX 407 

later also in the daytime, especially when the child exerts itself in 
any way. Usually no pain is experienced on swallowing and thus 
months may elapse before the slowly progressing symptoms, accen- 
tuated, perhaps, by repeated severe paroxysms of coughing or of 
suffocative attacks, compel serious attention. 

Diagnosis. — In all cases of long-standing stubborn laryngitis, a 
papilloma should be suspected, but a positive diagnosis can, of course, 
only be made by the use of the laryngoscope. 

Prognosis. — Papillomata sometimes disappear spontaneously if the 
larynx is given absolute rest for a few months. Surgical removal is 
followed by immediate and pronounced relief, but there is always a 
possibility of recurrence; indeed, removal seems to stimulate the 
growth of subsequent crops. 

Treatment. — Treatment should be entrusted to a skilful laryngolo- 
gist, who, if the child is tractable, may decide either on the endolaryn- 
geal method of removal with the forceps or wire snare. Occasionally 
thyrotomy or laryngofissure with curettage may be resorted to. The 
latter, however, greatly endangers the quality of the voice and, aside 
from the difficulty of anesthetizing the patient, there is the risk of 
postoperative bronchial pneumonia. To prevent recurrence the 
long-continued use of Fowler's solution has been recommended as 
one of the best prophylactic measures. 

FOREIGN BODIES IN THE LARYNX, THE TRACHEA, AND 
THE BRONCHI. 

Particles of food, buttons, pins, tacks, seeds, pebbles, bullets, and 
coins, in fact, all objects which a child playfully puts into its mouth, 
can, if small enough, be aspirated into the larynx or the trachea during 
an attempt at crying or laughing, or a sudden inspiration occasioned 
by an attack of coughing, hiccoughing, or choking. The resultant 
symptoms will naturally depend .upon the size, the shape, and the 
nature of the object swallowed and the age of the child; for even very 
small bodies may cause dangerous symptoms in the infant owing to 
the small size of its larynx. As a violent fit of coughing and of suffoca- 
tive attacks usually follows the accident, this frequently helps to 
expel the foreign body or to make it slip along the trachea into one of 
the bronchi, usually on the right side, owing to local anatomical con- 
ditions. Sharp objects like fish bones, pins, shells, etc., instead of 
becoming dislodged often become imbedded in the larynx and produce 
edema or occlusion of the glottis, which may result in sudden death 
unless immediate relief is given. Or they may penetrate so deeply 
into the soft tissue thay they cannot easily be seen or felt, so that 
either blood-stained sputum, a. spasm of the glottis, severe inflam- 
mation, edema, perichondritis, or an erosion of the bloodvessels may 
result. The severe lesions finally may lead to a certain degree of 
permanent stenosis owing to cicatrices that form during the process 
of healing. The object which has passed down the trachea may cause 
a great variety of other symptoms besides the paroxysmal cough, 



408 DISEASES OF THE RESPIRATORY TRACT 

the bloody sputum, and the localized pain in the chest. A whole lung 
or part of it may become atelectatic, depending on the size of the 
bronchus occluded, with absence of respiration and diminished 
resonance. Sometimes the inspired body acts as a valve and permits 
only inspiration, thus causing a rapidly developing emphysema with 
all its concomitant physical signs. If the foreign body is not removed 
it excites a local inflammation which, spreading to the surrounding 
lung tissue, may result in the development of pulmonary abscesses. 
These in turn may produce a high irregular septic fever that may end 
fatally with symptoms that somewhat resemble pulmonary tuberculosis. 

Diagnosis. — The diagnosis can usually be made from the history of 
"something having been swallowed the wrong way," the suddenness 
of the attack and the violence of the early symptoms. Digital exam- 
ination is somewhat dangerous, but Roentgen rays are a great help in 
many cases. Older children can be quieted down sufficiently for an 
examination by the laryngoscope or the bronchoscope, but this may 
prove rather difficult with a young child. It may be mentioned, in 
passing, that a lateral pharyngitis may be responsible for the sensa- 
tion of a foreign body in the throat. On the other hand, a troublesome 
cough with some physical signs of bronchitis or of pneumonia in a 
young child that presents increased respiratory movements on one 
side, and diminished vesicular murmur on the other, will suggest the 
possibility of an obstructed bronchus. 

Prognosis. — The prognosis is rather uncertain, much depending upon 
the nature of the foreign body and its location; for even when situated 
below the larynx it is by no means impossible for it to be expelled 
spontaneously. Suffocation is the most frequent cause of a fatal 
termination, especially when the object is large enough completely to 
obstruct the laryngeal opening. 

Treatment. — Nothing should be done that may cause a sudden 
inspiration; emetics are therefore not advisable; nor should an instru- 
ment or the finger be rashly introduced into the larynx, while care 
should be taken not to push the obstructing body down into the 
trachea. Inversion of the patient, in the hope of thus assisting 
Nature's effort to expel the offending particles by coughing, may be 
tried. Immediate tracheotomy may become necessary, but intubation 
is contra-indicated. Urgent cases admit of no delay, and a skilled 
laryngologist should be called immediately since only a specialist 
should undertake to remove a foreign body from the trachea or the 
bronchi. 



DISEASES OF THE BRONCHI. 

ACUTE BRONCHITIS. 

Acute bronchitis is an inflammation of the mucous membrane of the 
trachea and the bronchi with a tendency, more pronounced in infants, 
to involve the small bronchi as well. 



ACUTE BRONCHITIS 409 

Etiology. — It is often observed during the course of infectious 
diseases, especially measles, scarlet fever, pertussis, or epidemic grippe, 
but the essential etiological factor of simple bronchitis is, no doubt, 
an inflammation caused by the single or combined action of the staphy- 
lococcus, pneumococcus, influenza bacillus and Bacillus catarrhal is, 
or by the bacilli of typhoid and of diphtheria. Since the normal 
mucous membrane destroys the majority of invading germs, it is to 
be assumed that something diminishes this self -protective power and 
thus makes it easy for pathogenic bacteria to invade the deeper regions 
of the respiratory apparatus and there to multiply. In some chil- 
dren, especially fat, flabby, and pasty-looking ones, there may be an 
individual predisposition of the mucous membrane itself; this theory 
would at least explain why apparently the same cause will produce 
a simple catarrh in one child, and a diffuse bronchitis or an intestinal 
disturbance in another child of the same family. 

Very young children (between three and six months of age) show a 
marked susceptibility which, however, rapidly decreases in the fourth 
year. Lowered vitality from any cause naturally weakens the local 
resistance in children even more so than in adults; hence, mouth- 
breathing, chronic nasopharyngeal affections, glandular and other 
forms of tuberculosis, anemia, syphilis, and similar conditions, favor 
the development of bronchitis. Lack of hygiene, uncleanliness, sun- 
less dwellings, want of care (constant dorsal position), undue exposure 
either during the daily bath of the infant or by insufficient clothing, 
not to speak of bare legs during inclement weather (favored by a 
barbarous custom of endeavoring to "harden" the child), wet feet, 
raw winds, sudden atmospheric changes, are all frequently responsible 
for bronchial attacks. While it is true that a sudden chilling of the 
body surface may be harmful, on the other hand we can not too strongly 
condemn the excessive anxiety which, during the cold months, keeps 
children confined in close, overheated, ill-ventilated rooms, in school 
or at home, and compels them to breathe impure, germ-laden air. 

Pathology. — Our concern here is not with a localized bronchitis 
secondary to pulmonary disease, but with an acute catarrhal process. 
This is usually bilateral, rarely appears in patches, and primarily 
affects the mucous membrane of the trachea and the bronchi. The 
mucous membrane is injected and swollen, its glands and its goblet 
cells are markedly increased in number and pour out an excess of 
secretion, which soon changes from serous to mucopurulent, and con- 
tains desquamated epithelium, many bacteria, and leukocytes. In 
acute attacks the lymph nodes at the root of the lung are slightly 
swollen, the swelling being more marked in protracted or recurrent 
attacks. The mucosa and submucosa are infiltrated with small round 
cells and pathological bacteria. The mflammation is limited to the 
bronchial walls. An extension to the peribronchial tissues would be 
bronchopneumonia, as is also the so-called capillary bronchitis of 
children which, postmortem, shows changes in the air vesicles sur- 
rounding the bronchioles. In chronic bronchitis the mucous mem- 



410 DISEASES OF THE RESPIRATORY TRACT 

brane is thickened and of a brownish-red color, while a certain 
amount of emphysema, dilatation of the smaller bronchi, and some 
degree of peribronchitis are quite frequently found, especially in 
infants. 

Physical Signs. — Auscultation may be negative at first, but with 
increasing secretion bronchial fremitus is present. Percussion is also of 
little assistance except for the early detection of a possible pneu- 
monia. Sometimes there is some hyperresonance due to a transitory 
emphysema over the border of the lungs. 

Auscultation is usually of little value as long as the catarrh is dry 
and is limited to the trachea and the large bronchi, but sibilant, whis- 
tling rales appear early in the disease and are replaced within twelve 
to twenty-four hours by moist, bubbling rales; these are medium or 
coarse according to the size of the bronchi involved. They are most 
distinct between the scapula and in the intraclavicular spaces but 
can be heard all over the chest, changing frequently, and appearing 
and disappearing with the paroxysms of coughing. The vesicular 
murmur is feeble, expiration is often prolonged and rather harsh over 
the supra- and intrascapular region, simulating bronchial breathing. 

The base of both lungs should be carefully and frequently examined 
for fine, crepitant rales, which would indicate an incipient pneumonia. 
The loud, wheezing sounds sometimes persist for two or three weeks 
following the acute stage. The physical signs sometimes very closely 
resemble those of asthma, especially in the presence of spasmodic or 
of asthmatic elements. 

Symptoms. — The milder form, in which the affection is limited to 
the larger tubes, is very common indeed. It is not serious in older 
children, but in infants there is always danger of a complicating capil- 
lary bronchitis or bronchopneumonia. When a catarrh of the upper 
air passages extends to the bronchi — as in some children is the case 
after almost every coryza — it manifests itself by a cough, by slightly 
accelerated breathing, and by a further rise of temperature. It is 
usually the paroxysmal, tight, ineffectual, annoying cough which 
attracts attention; worse at night at first, it becomes looser and less 
irritating within a few days. The respirations, often accompanied 
by rattling in the late stage, may be accelerated to 40 or 50 per minute. 
The temperature, irregular in character, runs from 100° 'to 102° F. 
for two or three days, then sinks below 100° F., and usually returns 
to the normal within a week. There is no marked constitutional 
disturbance; in fact, there is very little danger except in young and 
delicate infants, older children being hardly sick enough for bed after 
the first or second day. There is, however, a moderate degree of rest- 
lessness, depending upon the severity of the cough, some substernal 
soreness in older children, also gastro-intestinal symptoms with vomit- 
ing and diarrhea in the very young patient. 

Children under five years of age do not expectorate unless they are 
" experienced coughers," but they swallow the secretion as it is coughed 
up. In older patients the expectoration consists of a white, frothy 



ACUTE BRONCHITIS 411 

mucus during the first few days, which later on becomes more abundant 
and of a yellowish-green tinge. 

In the more severe types of simple bronchitis all the symptoms are 
more pronounced, due to the involvement of the smaller tubes. The 
onset may be gradual, following a rhinitis or a pharyngitis, with pro- 
dromal fatigue, malaise and headache, but it is often abrupt, accom- 
panied by chills, or by convulsions in infants, and by fever, pain in 
the head, the back and the chest, and a dry cough closely resembling 
that of incipient pneumonia. The cough, the most prominent symp- 
tom, is absent only in weak infants, and is of the same character as in 
the milder cases, except that it is considerably more severe and more 
troublesome, and at times, is associated with pain or. even vomiting. 
It not infrequently lasts some time after all the physical signs have 
disappeared. In the early stages the expectoration is occasionally 
blood-streaked and later becomes profuse and mucopurulent, caus- 
ing a persistent cough, especially in the morning on awakening. 

The respirations are hurried, perhaps somewhat labored, though 
ordinarily there is no evidence of real dyspnea. But, as the inflam- 
matory process extends deeper into the bronchial tree, respiration 
becomes more rapid and superficial. In children 40 or 50 respirations 
per minute are not necessarily serious, but with an increase to 60 or 
80, accompanied by flaring of the alse nasi and participation of the 
accessory respiratory muscles, together with inspiratory retraction, 
marked cyanosis and prostration, and unduly prolonged expiration, 
a bronchopneumonia, or so-called capillary bronchitis, may be appre- 
hended. Weak and very young infants are the only exceptions to this 
rule, inasmuch as with them dyspnea and recession of the soft parts 
occur even in an uncomplicated bronchitis. Respiratory failure and 
suffocative attacks may develop quite suddenly, especially in infants 
under six months of age, who are unable to empty their tubes of secre- 
tion by coughing or by crying. The irregular, superficial breathing 
and the clammy, cyanotic skin produce dulness, apathy, and stupor, 
and unless promptly relieved convulsions and death may follow within 
a few hours. The temperature is not characteristic; during the first 
few days it runs up to 102° or 104° F., but if no complications arise 
it gradually falls to normal within a week. The constitutional svmp- 
toms abate with the fall of temperature and seldom cause anxiety 
except for the first twenty-four to thirty-six hours. Inspection of the 
bared chest show T s nothing beyond rapid breathing and slight inspira- 
tory retraction of the soft parts. When exaggerated (except in very 
young or weak infants) , the latter sign, together with increasing dyspnea 
and cyanosis, becomes an important danger signal of incipient broncho- 
pneumonia. 

Prophylaxis. — All infants and children, especially those suffering 
from syphilis, rickets, and nutritional disturbances, should be care- 
fully kept from close contact with persons afflicted with colds, rhinitis, 
tonsillitis, grippe, etc. If in spite of all precautions they become 
affected with catarrh of the upper respiratory passages, treatment 



412 DISEASES OF THE RESPIRATORY TRACT 

should be prompt and careful, and should be continued until con- 
valescence is completely established, for tuberculosis may develop 
in the inflamed bronchial glands. Adenoids and diseased tonsils 
should be removed when necessary, preferably during the warm season 
of the year. 

Treatment. — While fresh air is of the greatest importance, the 
advantage of inhaling a great deal of cold air has not yet been demon- 
strated. The sleeping apartments of susceptible children should be 
well ventilated but the temperature should not register less than 60° 
F. if possible. During cold weather the clothing should be sufficiently 
warm but not cumbrous, and the house should be kept at as equable 
a temperature as possible. A warm dry climate (sometimes mild sea- 
air does equally well) is a boon during the winter months, especially 
for the child with a tendency to pulmonary disease or one with tuber- 
cular antecedents. Generally speaking, the mild case requires little 
treatment beyond careful nursing and feeding, while the more severe 
type must be treated as bronchopneumonia. As long as there is fever, 
the patient should be confined to bed in a bright, large room, preferably 
with an open fireplace, to ensure thorough ventilation, and a screen 
as a protection against draughts. To prevent hypostatic congestion, 
delicate infants must be frequently taken up, or, at least, their position 
must be changed. They should be kept warm, though this does not 
mean bundling them up in blankets or warm shawls, as is frequently 
done. 

The Diet. — The nursing infant has a much better chance of recovery 
than the bottle-fed baby. If its temperature rises above 100° F., 
and the little one is restless and irritable, it may be advisable to 
shorten the time of nursing to one-third or one-half the usual time, 
and give a few ounces of sweetened water before nursing. For bottle- 
fed babies it is well to reduce the strength of the milk formula and to 
give plain boiled or slightly alkaline water between feedings. Older 
children, while confined to bed, may be allowed a light diet consisting 
of toast, milk, cocoa, broths, gruels, and fruit juices. 

While pure air, the importance of which has already been empha- 
sized, usually contains enough moisture, inhalations of medicated 
steam for half an hour at a time and repeated at intervals of several 
hours are of great service in the treatment of acute bronchitis. Creo- 
sote, 10 drops to a quart of water, seems the best, but benzoin and 
eucalyptus have also proved useful. A tent may be improvised with 
sheets spread over the top and sides of the child's bed, and the nozzle 
of the croup-kettle, from which the steam flows, introduced within at 
a safe distance from the face and head of the child. Fresh air is 
admitted from time to time by raising the sheet. 

During the first few days counter-irritation affords one of the most 
efficacious means of bringing the blood to the surface and thereby 
relieving pulmonary congestion. A paste made of one part of mustard 
and three parts of flour mixed with warm water and the white of an 
egg, and spread one-eighth of an inch thick on a piece of old linen, 



ACUTE BRONCHITIS 413 

cheesecloth, or muslin, is applied to the chest between linen cloths 
and left in place until the skin is well reddened. After its removal, 
vaseline, or, better, talcum powder gently applied will relieve the 
burning sensation. The hot mustard bath, \ ounce of mustard to 
() gallons of water at a temperature of 107° to 110° ¥., is especially 
useful when the rapid respirations and the cold extremities indicate 
an impending bronchopneumonia. The hot mustard pack (a sheet 
wrung out of hot mustard water) sometimes proves equally useful. 
These procedures can be repeated every four to eight hours; should 
the skin become very sensitive, the proportion of mustard may be 
reduced. 

An old remedy of great value in some cases is dry-cupping over the 
chest and the back from five to ten minutes at a time; this can be 
repeated every few hours if necessary. 

Drugs. — The treatment of bronchitis by drugs is entirely symptomatic 
and unimportant. Of course, an initial purge of castor oil, repeated 
every three to four days, is good in helping to relieve the intestinal 
canal of the swallowed mucopurulent materials. During the first 
stage, characterized by a dry cough and rough breathing, castor oil 
and syrup of ipecac, 2 to 3 drops each for infants, and 4 to 5 drops 
for children three years old, repeated every two to three hours foi the 
first three days, will help to liquefy the secretions and lower the fever. 
It would be injudicious to suppress the cough; but, if very distressing, 
the following simple prescription may add to the patient's comfort: 

1$ — Pot. brom gr. 1 

Timet, bellad Ill xv 

Glycer. fo ij 

Elix. lact. peps q. s. gij 

One f3 every three hours for a child one year old. 

For older children, tinctura opii camphorata, 1 to 2 fluidrams, may 
be added. Or a tablet or a powder may be given as follows: 

At age of At age of one After 

six months. to three years, three years. 

3— Tartar emetic r^o ih sV 

Powdered ipecac T V to 2V 

Amnion, chlor. h J 1 

For a severe cough add Dover's powder -g- ^ 
Two-hour intervals, eight doses in twenty-four hours. 

Antipyretics are hardly ever needed, as the temperature can be con- 
trolled by warm tub or sponge baths, which have the additional advan- 
tage of quieting the nervous system and stimulating the action of the 
skin. Emetics, J to 1 dram of either the wine or the syrup of ipecac, 
were formerly used extensively for clearing out the tubes, but they 
are very depressing, and only in exceptional cases should they be 
given to children under two years of age. Guaiacol in a 10 per cent, 
ointment is easily absorbed by the delicate skin of an infant, and when 
so used does not cause any digestive disturbance. Quinine, still 
believed by many to be anticatarrhal, can be given by rectum in sup- 
positories. 



414 DISEASES OF THE RESPIRATORY TRACT 



DISEASES OF THE LUNGS. 



PNEUMONIA. 

In early life the lungs, more frequently than any other organs, are 
attacked by acute or subacute inflammation, either as a primary affec- 
tion or secondary to acute infections. The pathology and symptoms 
of the inflammatory process vary according to the pathogenic organ- 
isms present and the extent of the lesions. The two leading types are: 
(1) lobar, fibrinous or croupous pneumonia, a sharply circumscribed, 
inflammatory process involving an entire lobe or the greater portion 
of it, without affecting the walls of the bronchioles and the alveolar 
septa. Both the onset and the termination are rather sudden, the 
disease running its course within a few days; (2) the lobular type — 
bronchopneumonia — involving the walls of the bronchi as well as the 
individual lobules of the lungs, and forming small irregularly dis- 
tributed areas of consolidation. The exudate is composed mainly 
of cells with very little fibrin. The duration and course of this type 
are more or less indefinite and the termination takes place by lysis. 
In typical cases, these two types are quite distinct, but intermediate 
forms may occur, especially during the second and third years of life, 
more or less resembling both types. 

Lobar Pneumonia. — This form, though rare in infants, is not at all 
uncommon after the first year. It is an acute infectious disease, 
running a well-defined course, and differing in no essential details 
from the adult type. In typical cases pneumococci (diplococci pneu- 
moniae of Frankel or of Weichselbaum) are often found in the blood 
and in great numbers in the lungs, either as pure cultures, or predom- 
inating over the associated streptococci and staphylococci. 

Pneumococci are normally present in the saliva and on the mucous 
membrane of the respiratory passages of healthy children; it is, there- 
fore, self-evident that they incite disease only when the local or the 
general powers of resistance are lowered. Traumatic and other 
predisposing influences naturally also play an etiological role; a blow 
on the chest, a fall, fatigue, the inhalation of irritating vapors, and, 
above all, undue exposure to raw winds and inclement weather, are no 
doubt responsible for precipitating many an attack. Fully two-thirds 
of all cases occur during the winter and early spring months, especially 
after a sudden fall of temperature accompanied by wind and rain that 
follows a period of depressing heat — conditions that account for 
lobar pneumonia being spoken of as a "house disease." The disorder 
occasionally follows grippe, typhoid fever, or whooping-cough. x4s 
a rule it affects children previously healthy ; that is to say, if a healthy 
child contracts pneumonia it is usually of the lobar type. As in 
adults, repeated attacks within a year may be attributed to a family 
tendency to the disease. Boys are more often affected than girls, prob- 
ably because they are more likely to be exposed to weather conditions. 



PNEUMONIA 415 

Morbid Anatomy. — The anatomical changes, seldom seen postmortem 
on account of the low mortality of the disease in children, closely 
resemble those of the adult type, except that the line of demarcation 
is less well defined, because the pneumococcus may produce either 
pneumonia or bronchopneumonia or both at one time, together with 
a more or less pronounced pleurisy. Generally an entire lobe or the 
great part of it is affected, but several lobes, both apices, or a whole 
lung may be involved. 

During the first stage — that of congestion — which may last from 
a few hours to several days, the epithelial lining of the alveoli becomes 
turbid and swollen owing to the rich fibrinous exudate that pours 
into them. The second stage is that of red hepatization, so called 
because the affected portion of the lung resembles the liver, being red, 
heavy, tough, and granular on section due to fibrin blocks in the 
alveoli. It may last anywhere from a few days to one or two weeks. 
This is followed by a shorter third stage — that of gray hepatization. 
The lung then appears bulky, soft, yellow and bloodless, with costal 
imprints. The contents of the alveoli gradually disappear by absorp- 
tion rather than by expectoration. Resolution sets in with the fall 
of the temperature or soon after, and is complete in about a week. In 
addition to these pulmonary changes the mucous membrane of the 
neighboring bronchi as well as of the pleura shows signs of inflamma- 
tion. Pathological changes, due to complications, such as fibrinous 
or purulent pericarditis, especially in left-sided pneumonia with 
pleurisy, or, more rarely, pneumococcic meningitis, peritonitis, ar- 
thritis, may become manifest before, during, or after the attack of 
pneumonia. 

Physical Signs. — The little patient is apt to be restless and irritable, 
and examination is not always easy. Nevertheless it should be 
repeated at frequent intervals, because consolidation with all its con- 
comitant signs may appear within a few hours after a negative finding. 
Sometimes the only indications in an otherwise typical attack are a 
brief impairment of resonance and a few rales, and again flushed cheeks, 
herpes of the lips and the nose, short, rapid, superficial respiration, 
the flaring ake nasi, and possibly a deficient expansion of the affected 
side may give a clue as to the correct diagnosis, when for days and 
even up to the crisis the characteristic physical signs are delayed. 
Usually, however, as in the adult type, the three stages of congestion, 
consolidation, and resolution also occur in children. 

Percussion. — Percussion of the bases is, of course, a routine procedure, 
but it is very important not to omit an examination high up in the 
axillary and the infraclavicular regions. Impaired resonance or slight 
dulness may often be elicited over the affected area, and a somewhat 
increased resonance over the rest of the lung, according to the dimin- 
ished or increased amount of air entering the lungs. ^Yhile dulness 
is likely to be absent in the infant, tympany may be obtained even 
over a consolidated lung when it overlies a distended viscus, the 
stomach, for instance. The tactile vocal fremitus is of little diagnostic 



416 DISEASES OF THE RESPIRATORY TRACT 

value in children, as it would be altogether absent over the area of an 
occluded bronchus on account of their thin, high-pitched voices. 

Auscultation. — The vesicular murmur is very early diminished over 
the affected portion, and breathing over the opposite lung becomes 
harsher. This puerile respiration, due to vicarious emphysema, must 
not be mistaken for bronchial breathing, which, as is well known, 
lacks the vesicular element and is more intensive on expiration. 
With the inverted type of breathing, so often present in pneumonia, 
it may, however, give the impression of being louder on inspiration 
than on expiration. Bronchial breathing and bronchophony over 
a sharply defined consolidated portion are most valuable signs; they 
may often be heard as early as the second day in basal pneumonia, 
and by the fourth or fifth day are usually audible over the spine of 
the scapula in apical cases. 

In order to bring out these signs more clearly it may be necessary 
to cause deep breathing by inducing coughing or crying, or by having 
the child lie on one side while examining the other, thus allowing the 
air to enter more freely. In this way a high-pitched, tubular breathing 
and crepitation may be revealed which at once clinch the diagnosis. 
This crepitation is best heard at the end of inspiration, either as a 
crepitus indux disappearing with consolidation, or as a crepitus redux 
reappearing with resolution; but medium or coarse rales are much 
more common in children. Very often when one lung is affected, these 
signs are also audible over the other side. This is merely due to 
transmission; the faint character of the abnormal sounds as well as 
the absence of impaired resonance should be sufficient to prevent a 
mistaken diagnosis of double pneumonia. Occlusion of a bronchus 
may produce such complete absence of all breath sounds as to suggest 
the presence of a fluid. Rales and a pleuritic friction rub are usually 
absent during the stage of consolidation, while during resolution the 
signs of consolidation disappear gradually. The tubular quality of 
the expirations and all kinds of moist rales are gradually replaced by 
a vesicular murmur, and friction sounds are also sometimes heard. 
The physical signs clear up with remarkable rapidity, as a rule within 
a week, but occasionally a slightly diminished resonance and a feeble 
vesicular murmur may persist for several weeks. 

Symptoms. — By the second or third day herpes of the lips or the 
nose usually appears, the tongue shows a whitish or yellowish coat, 
the temperature and respiration continue high and rapid, and the 
bowels are usually constipated. About this time the physical signs 
also set in, although they may be delayed for a few days. Toward the 
seventh day all the symptoms are aggravated and alarming, perhaps 
with severe delirium, when the crisis occurs with its sudden change. 
The fever abates, the body becomes moist with a warm perspiration, 
the cough grows looser, respiration less rapid, and after a quiet 
sleep the child awakens refreshed, with a slow pulse and often a sub- 
normal temperature. Unless the inflammatory process spreads to 
another lobe or a complication arises, the tongue clears and the appetite 



PNEUMONIA 417 

returns. The child now wants to sit up in bed, and at the end of the 
second week recovery seems established except, perhaps, for a few 
rales and a slightly impaired resonanee over the affected area. 

In children from seven to eight years of age the elinieal picture 
closely resembles that of the adult, but younger patients differ in the 
ease with which the immature organism, especially the nervous 
tern, is upset. The constitutional symptoms seem to depend not so 
much on the extent or the seat of the local affection as on the toxemia 
produced. This may be meningeal, gastrointestinal, migratory, or 
nephritic. As in other infectious diseases, abortive cases are occasion- 
ally observed. At the onset these present all the sign> of the first 
stage of pneumonia, but clear up so quickly that even the keenest 
observer may well doubt the correctness of his diagnosis. Some mild 
but indubitable cases may last only three or four days, but typical 
lobar pneumonia in childhood runs a definite course of at least five to 
nine days. After a few hours, sometimes even days, of prodromal 
lassitude, discomfort, or a slight cold, profuse and sometimes repeated 
vomiting suddenly takes place. This may be accompanied by diarrhea, 
chilly sensations, epistaxis, or even convulsions. The temperature 
rises sharply to 103° or 104° F., the child looks ill, appears heavy and 
dull, refuses food, and is easily persuaded to go to bed. It may complain 
of headache or of earache, and also of severe abdominal pain suggest- 
ing appendicitis; sharp costal pain, however, is a rare symptom in 
children under six years of age. The next day the fever continues 
high, the cheeks are flushed, the skin is burning hot, the eyes sparkle, 
the ala? nasi vibrate; the child, though willing to stay in bed, is rather 
restless; and during the night it may be drowsy or delirious, breath- 
ing rapidly, with a short expiratory moan or grunt. The short, dry 
cough, if present, is often very slight at first, though occasionally it 
may be so painful as to induce crying, but it is not followed by 
expectoration. "Whatever sputum can be obtained with a swab shows 
the typical, characteristic, tenaciousness and rusty color. 

The facial expression appears neither anxious nor distressed in 
spite of the rapid respiration. The cheeks are not always flushed — 
in fact, sometimes there is marked pallor. Herpes of the lips and the 
nose is frequently absent in infants under one year of age. As a rule, 
there is no true dyspnea, the accessory muscles remain inactive, but 
the breathing is shallow and mainly abdominal, sometimes irregular, 
and always disproportionally rapid (40 to 60 or more respirations per 
minute) compared to the pulse rate and the temperature. The 
cardiorespiratory ratio is, however, not so significant as in adults owing 
to the ease with* which the pulse in children is accelerated for any 
slight cause. An expiratory grunt or moan with the pause after inspira- 
tion is often observed. The range of temperature is irregular in infants, 
oscillating one to three degrees or more, but in robust and older chil- 
dren it often shows the adult type — sudden rise to 103° to 105° F., 
with slight diurnal variations, finally ending by crisis on the fifth, 
seventh or ninth day, unless the inflammatory process spreads or 



418 DISEASES OF THE RESPIRATORY TRACT 

complications arise. In such cases it may not end before the four- 
teenth day, and then by lysis. 

Pseudocrises are a good omen, and are much more common in chil- 
dren than in adults. The inflammation of the lung itself does not 
seem to be the direct cause of the fever because the temperature often 
reaches its maximum and falls before there is any evidence of change 
in the lungs. 

The Pulse. — The pulse, at first full, bounding, and slightly accel- 
erated, becomes small, rapid, irregular, and of low tension, as the 
toxemia increases; this together with the cyanosis and the venous 
pulsation indicating a weakened heart. 

Gastro-intestinal Symptoms. — Besides the furred tongue, the failing 
appetite, the diarrhea or constipation, jaundice and vomiting may 
be early symptoms. Meteorism, or abdominal distention may last 
throughout the course of the attack and are particularly distressing 
because they embarrass cardiac and' pulmonary action. 

Cerebral Symptoms. — These seem to be dependent more on the 
degree of fever and the virulence of infection than upon the par- 
ticular portion of the lung affected. They may vary from slight 
wandering to active delirium with incontinence of the feces and the 
urine. In infants and young children unable to formulate their 
complaints, restlessness, muscular twitching, and a retraction of the 
head may sometimes be so severe as to simulate cerebrospinal menin- 
gitis, while again restlessness, apathy, and, later, drowsiness are the 
only cerebral manifestations. 

The Crisis. — The crisis usually occurs between the fifth and the 
eighth day of the disease, or earlier in exceptional cases, though some- 
times it sets in as late as the ninth or tenth day. Should the fever 
continue beyond that time it is likely to end by lysis. After the criti- 
cal fall the temperature may be subnormal for a few days, and although 
the danger of collapse in children is less than in the adult, the patient 
should be watched with special care during this time. 

The Blood. — From the time of the first chill the leukocytes increase 
rapidly up to 40,000 or 70,000. The count returns to the normal 
number a few days after the crisis, but it may persist high for weeks 
in complicated cases or when resolution is delayed. While a low leuko- 
cytosis indicates reduced resistance and augurs ill, a high white cell 
count is not necessarily a favorable prognostic sign. Pneumococci 
are found in the blood cultures in about 50 per cent, of all cases even 
before the appearance of the characteristic physical signs in the lungs. 

The Urine. — The urine, as in all fevers, is scant and dark, with a 
high specific gravity and increased acidity, and contains casts and a 
trace of albumin. The chlorides are reduced, or even absent, but 
reappear at the time of the crisis, when the total quantity of urine 
is also greatly increased. 

Diagnosis. — Diagnosis is clear in the typical case; but in the atypical 
case, the late appearance of the characteristic physical signs and the 
great variety of general symptoms may puzzle the physician for several 



PNEUMONIA AW) 

days, unless the diagnosis is definitely established by a bacteriological 

examination of the sputum. 

The most common error is to mistake pneumonia for some other 
disease rather than the reverse: Considering how frequently this 
mistake is made in children, a continuously high temperature, with 
rapid respirations and marked leukocytosis, should arouse a suspicion 
of pneumonia, no matter what the other symptoms may be. A careful 
search for the physical signs high up in the axilla may often be of use 
in establishing the diagnosis. 

The onset of scarlet fever, tonsillitis, gastro-intestinal disturbances, 
and malaria may resemble that of pneumonia; but the appearance 
of the characteristic rash on the second day in scarlet fever, the 
aggravation of local symptoms in tonsillitis, the rapid decline of fever, 
as well as the improvement in the constitutional symptoms produced 
by laxatives and proper feeding in gastro-enteritis, and, finally, the 
fact that chills followed by a sharp rise in temperature and marked 
leukocytosis are rarely seen in malaria, make the differentiation com- 
paratively easy. On the other hand, it is often impossible during the 
first few days clearly to distinguish a bronchitis with high fever from 
pneumonia. A rapid course with severe dyspnea and cyanosis without 
corresponding physical signs in the lungs, especially in the infant. 
may suggest miliary tuberculosis until the subsequent course of the 
disease, the temperature range, and an examination of the sputum. 
together with the history of the onset, make the diagnosis clear. The 
constitutional symptoms of influenza, if the catarrh of the conjunctiva 
and the upper air passages is not marked, may at first simulate 
pneumonia, but the appearance of marked leukocytosis and of the 
physical signs, as well as the course of the disease and the bacterio- 
logical findings in the sputum, soon dispel all doubt. Initial vomiting, 
abdominal pain, tenderness, and distention, especially when asso- 
ciated with slight resistance on the right side, so strongly suggest 
appendicitis, that operation has actually been resorted to in such cases. 

It is therefore important to make a careful examination in everv 
case. The sudden rise of temperature to 103° or 104° F., the con- 
tinuous type of the fever, the disproportionately rapid respirations, 
the relaxation of the abdominal walls between respirations, the ten- 
derness diminishing or disappearing on deep pressure with the flat 
hand, and the possible cough, will put the careful observer on his 
guard. Pneumonia is sometimes masked by intense cerebral symp- 
toms — vomiting, convulsions, delirium or stupor, rigidity of the 
muscles of the neck and opisthotonos — and may be mistaken for 
cerebrospinal meningitis; in the absence of the physical signs in the 
lungs, it may be several days before a definite diagnosis can be made. 
The difference, however, may be noted in the absence of the slow, 
intermittent pulse and the slow irregular respirations as well as of the 
dilated pupils of meningitis and the signs of paralysis. Another 
differentiating factor is the presence of the nervous symptoms at the 
onset of pneumonia, while in meningitis they come on so slowly that 



420 DISEASES OF THE RESPIRATORY TRACT 

by the time the resemblance between the two ailments is closest the 
physical signs in the lungs will have made their appearance. 

When typhoid fever with a sudden onset and high temperature is 
associated with symptoms of pulmonary involvement, as is the case 
with children, the diagnosis may be doubtful until the presence of 
leukopenia, or of roseola, or a diazo, or a positive Widal reaction leave 
no room for doubt. The physical signs of atypical cases of pleural 
exudation may so closely resemble lobar pneumonia that the diagnosis 
can be made only by exploratory puncture. In pleurisy the area of 
dulness shifts somewhat with a change of position, and is usually 
greater, while the flatness is more marked behind and below, and 
gradually increases instead of disappearing with the decline of tem- 
perature. The greater resistance noticed on percussion over the 
intercostal spaces, their markedly unilateral fulness or bulging, the 
limitations of respiratory excursion, the displacement of the heart 
and perhaps the liver, and, finally, egophony, when present, all favor 
effusion. While the bronchial voice is distant and the intensity of the 
respiratory sounds is diminished in the majority of young patients, 
they are not altogether abolished as in the adult. The bronchial 
breathing is feeble and most marked at the upper border of dulness; 
while in pneumonia it is louder and most pronounced in the area of 
maximum dulness. 

Prognosis. — Unless complications arise, pneumonia is rarely fatal 
in children, especially after the second year (mortality being 2 to 5 
per cent.) ; although death may occur from otitis, meningitis, cerebral 
abscess, pericarditis, pleurisy, or toxemia — the toxins acting upon 
the vasomotor centres in the medulla and on the cardiac muscle fibers. 
As a rule, the heart stands the strain well, but fatal syncope has been 
known to occur during convalescence. In girls and -undernourished 
children resistance is diminished; while rickets, heart lesions, and 
previous lung affections distinctly reduce the chances of recovery. 
Convulsions are comparatively rare in children over two years of age; 
but should they occur toward the end of the disease a fatal issue may 
be expected. Neither a violent onset nor a high temperature, except 
when over 106° F., nor the severity of the initial nervous symptoms 
has much prognostic value. 

Treatment. — A large, sunny, quiet, well-heated sick-room, with an 
abundance of fresh air flowing in through windows, open both day 
and night, and an intelligent -nurse who can be relied upon tactfully 
to keep out visitors, and to watch the child with special care at the 
time of the crisis, are important in the general management of the 
case. The hours for feeding and medication should be so arranged 
that the patient can enjoy intervals of three to four hours of perfect 
rest. Milk, whey, meat juice, albumen-water, fruit juices and broths, 
will give the required amount of nutriment and fluid. If given at 
proper times, they will not overtax the weakened digestion, manifested 
in most cases by anorexia, vomiting, and diarrhea. While a very 
weak patient may require gavage feeding, overfeeding should be 



PNEUMONIA 421 

avoided, as it is apt to induce gastro-intestinal disturbances, fermenta- 
tion, and abdominal distention, which may considerably increase the 
resoiratory difficulty. The well-nourished child when attacked by 
pneumonia can, in the beginning, very well go without food for one or 
two days provided it is given plenty of water. 

If an ice-bag is used over the chest, the feet must be kept warm; 
the bag should be removed whenever the temperature falls below 
100° F., and not be replaced until it has again risen to 102° F. How- 
ever, a child usually dislikes extremely cold applications, and as their 
superiority has not been established warmth in some form seems 
preferable. This is applied by wringing a piece of flannel out of hot 
water, wrapping it around the thorax, and covering it snugly with 
several layers of flannel. The procedure can be repeated at intervals 
of a few hours without disturbing the child. Poultices are cumbersome 
and are rarely of any benefit. If applied over the thorax they, by their 
weight, tend to increase the respiratory difficulty, although this dis- 
advantage is obviated by allowing the child to lie upon the poultice. 
They are occasionally useful in relieving pain of an associated pleurisy. 
A mustard paste — left in place only long enough to produce redness 
but no blistering — and intermittent stupes will relieve the pain and 
combat pulmonary congestion by reflex action; although dry cups 
applied over the base of the lungs are more efficacious. 

Notwithstanding the fact that lobar pneumonia is a self-limited 
disease with a strong tendency to recovery, and that we know of no 
specific for it, and that overmedication certainly may do harm, there 
is no doubt that skilful treatment not infrequently saves life and 
always relieves the suffering of the little patient. In the ordinary, 
uncomplicated case an initial cathartic is indicated; this may consist 
of one or more teaspoonfuls of castor oil, or, if nausea and vomiting 
prohibit this, of small doses of calomel followed by citrate of magnesia. 
The bowels should be kept open throughout the entire course of the 
disease, especially in the very young, in order to prevent abdominal 
distention. A simple mixture of camphorated water containing 
potassium citrate and sweet spirits of nitre, given every three to six 
hours, may be of advantage in getting rid of the sputum that may 
have been swallowed. Expectorants such as ammonia, ipecac, or 
squills can usually be dispensed with as they seem to be a frequent 
cause of gastro-intestinal disturbance. Alcohol has lost much of its 
former popularity, being now chiefly reserved as a stimulant during 
the crisis; but weakly, undernourished children need it from the 
onset. Children under two years of age should be given 20 to 30 drops, 
sweetened and diluted in 6 to 8 parts of water, three times a day; 
it is especially indicated when the toxemia and the prostration are 
marked. Respiratory and circulatory stimulants may be needed, 
especially during or directly after the crisis, the most valuable being 
strychnine, gr. 3^ and atropine, gr. Tiro, aromatic spirits of ammonia, 
gtt. x, camphor monobromate, grain \, caffein citrate, gr. }, and 
soda benzoate or salicylate in 3-grain doses. These doses are suitable 



422 DISEASES OF THE RESPIRATORY TRACT 

to a child five years of age and may be repeated every three hours as 
long as may be necessary. Oxygen inhalations do good service when 
there is cyanosis with very rapid respirations. 

Other symptoms are treated as they arise. Convulsions can be 
controlled by chloral hydrate or sodium bromide administered by 
mouth or by rectum; for sleeplessness, the same drugs, with the 
addition of cold applications to the head are preferable to opiates. 
A dry, irritating cough, which does not yield to wine of ipecac, syrup 
of tolu, or tincture of belladonna, may call for small doses of heroin, 
paregoric, or codein. Fever exceeding 105° F., demands hydrothera- 
peutic measures, which if judiciously applied not only reduce the 
temperature but also quiet the nervous system and stimulate nutri- 
tion. All children do not react equally to baths; as a rule, tepid or 
moderately cool water is the choice, but a cool pack, or a sponge 
with alcohol and water may be better in certain cases. The coal tar 
derivatives are, of course, out of place as antipyretics, but for the 
relief of pain, headache, nervousness, and sleeplessness in children 
over two years of age, phenacetin in small doses is certainly helpful 
and is much used. When the nervous symptoms are pronounced, 
repeated warm baths at a temperature of 95° F. will usually prove 
efficacious. The child should not be immersed above the lower part 
of the ribs when sitting in the tub. In addition to this, for a child 
of two, a sedative, 4 to 5 grains of bromide with 1 minim of tincture 
of belladonna in elixir of lactated pepsin, will be beneficial. Opiates, 
besides being dangerous, are rarely necessary; although codeine, tV 
grain, or camphorated tincture of opium, 5 to 20 drops, is occasionally 
permissible for children three to five years of age, in order to relieve 
the excessive pain produced by the cough or the pleurisy. 

During the last few years, laboratory methods of treatment have 
gained some prominence. While leukocyte extract has not as yet 
been tried in a sufficient number of cases to allow of any definite con- 
clusions, it appears that there is a fairly constant reduction of tempera- 
ture after two to four injections. As for pneumococcus serum, Rowland 
G. Freeman regards a dosage of 100 to 150 c.c. a safe method for 
combating pneumonia in children. Very soon after the injection the 
majority of them seem to brighten up, the appetite and color appear 
improved, while the temperature is reduced, sometimes markedly so. 
Although the condition of the lung itself does not change much, as 
a rule, the average duration of the disease as well as the mortality, 
are slightly lowered. The reports as to the. value of vaccine, especially 
the autogenous, treatment continue to be contradictory. Morton 
Illman gives 400 to 500 millions of pneumococcic stock vaccine in 
every case of lobar pneumonia as soon as it has been diagnosed, and 
follows it with a second, slightly smaller, injection in two or three 
days. In some of the cases there is a prompt return to normal tem- 
perature and a marked amelioration of all the toxic symptoms; in 
others, a pseudocrisis takes place with a subsequent slight rise of 
temperature ending within twenty-four to forty-eight hours by lysis. 



BRONCHOPNEUMONIA 423 

Finally, there arc cases which to all appearances are not favorably 
influenced and which terminate; in the usual way. When streptococci 
or the bacilli of Friedlander are found in cultures of the sputum, it 

is, of course, necessary to add proportionate amounts of these to the 
vaccine in order to obtain good results. 

Convalescence. — A few days after the crisis, wh'en the physical 
signs are clearing up, the child may be allowed out of bed, and after 
the lapse of a week may be taken out of doors, provided the weather 
be favorable and there is no danger of complications. During con- 
valescence, warm clothes, a carefully selected, nourishing diet, and 
plenty of fresh air are ordinarily all that is needed. If the general 
improvement does not progress steadily, some tonic may be required, 
such as malt extract, and iron, the syrup of ferrous iodide, or the like. 

BRONCHOPNEUMONIA. 

The pathological condition described under this name is really a 
syndrome rather than a clinical entity per se } following more or less 
closely upon an infection of the upper air passages, or arising in the 
course of certain infectious diseases. Next to gastro-intestinal dis- 
turbances, it is the most common and the most serious trouble of 
infancy; its characteristic feature being an inflammation of the 
respiratory passages which extends to the minute bronchi and adjacent 
alveoli. The fact that the latter are not fully developed before the 
third or fourth year may partially explain the striking susceptibility 
of infants to this affection. While rare during the first six months, 
about 50 per cent, of all cases occur during the first year,. 30 per cent. 
during the second, and, approximately, 10 to 15 per cent, in the third 
year of life. It does not often appear as a primary disease after the 
fourth year, but it may occur throughout childhood as a complication 
of the acute infectious diseases. 

In only about one-third of all cases of bronchopneumonia is the 
disease primary; as such it is most commonly due to the pneumo- 
coccus, and in older children it probably manifests itself as lobar 
pneumonia. In the remaining two-thirds, nearly always due to mixed 
infection, it is secondary to simple bronchitis, measles, whooping- 
cough, or to influenza, and in delicate and in older children to scarlet 
fever or to diphtheria, especially in the laryngeal form after intubation 
or tracheotomy. No doubt a good many of these cases may be traced 
to the attitude of well-meaning but uninformed parents who, in their 
fear of colds, keep their children confined in close, overheated and 
poorly ventilated rooms. 

Poorly nourished, rachitic, or syphilitic children, especially when 
in institutions, are particularly predisposed to the disease, and should, 
therefore, be guarded from undue exposure during the winter months, 
in which bronchitis and infectious diseases are prevalent. Broncho- 
pneumonia is probably always due to the action of pneumococci but 
the bacilli of Friedlander, and the influenza bacilli, and more rarely 



424 DISEASES OF THE RESPIRATORY TRACT 

those of diphtheria may be found in all possible combinations of pre- 
dominance. Its severity is, however, not so much dependent on the 
particular organism as on the soil in which the organism flourishes. 

Pathology. — In older children, typical lobar and bronchopneumonia 
may at times be quite as distinctly differentiated as in adults, although 
there are cases, especially in children under four years of age, which 
cannot be definitely classified even with the aid of a microscopic 
examination. Again, both types may be found in different parts of 
the lungs in the same patient. 

Bilateral bronchopneumonia affects the posterior portion of the 
lower lobe about five times as frequently as it does other parts. The 
inflammatory process spreads through the walls of the bronchioles 
to the surrounding tissues, which become markedly infiltrated with 
lymphocytes. Pus oozes from the bronchioles on pressure, and their 
adjacent alveoli are more or less distended with epithelial debris as 
well as with white and perhaps some red blood corpuscles, serum, 
and a small amount of fibrin. At first these areas of peribronchitis 
are small — the size of a pea or smaller — and are surrounded by normal 
or gray emphysematous lung tissue appearing in the surface as purplish 
foci; later they become yellowish-gray and may increase to the size 
of a nut, or by coalescence they may sometimes affect the greater part 
of the whole lobe. The bronchial and tracheal lymph glands are also 
swollen. 

Symptoms. — There is no regular course of symptoms. As most 
cases of bronchopneumonia are secondary conditions, they are pre- 
ceded by febrile or afebrile manifestations of catarrh of the nose, the 
larynx, the trachea, or the larger bronchi, or as complicating symp- 
toms of infectious disease. The onset is therefore usually gradual 
with unmistakable pulmonary signs, thus contrasting with lobar pneu- 
monia with its often misleading initial abdominal or cerebral symp- 
toms. However, a sudden onset with a sharp rise of temperature, 
vomiting, and anorexia is not rare; and in the breast-fed infant the 
refusal to nurse is frequently one of the first signs of the disturbance of 
respiration. The breathing becomes more rapid and difficult, and the 
cough more constant. The child appears very ill and prostrated, and 
as the dyspnea progresses, the cyanosis and drowsiness deepen and 
the pulse and the cough grow weaker; finally, convulsions and coma 
may lead to a fatal termination after an illness of a week or two. 

Fortunately, more often the outcome is a happier one. After one 
or two weeks a more or less rapid abatement of all the symptoms is 
followed by a short pyrexial period, and then uncomplicated recovery, 
provided, of course, there is no relapse with its signs of involvement of 
fresh areas. This may, naturally, delay recovery for several weeks. 
An increasing cyanosis and respiratory distress, a feeble cough, con- 
sequent increased large moist rales in the trachea and the bronchi, 
a weakened pulse, together with a cold, clammy skin, a dull, listless, 
drowsy attitude — all indicate that the disease is progressing unfavor- 
ably. On the other hand, the fact that the symptoms do not grow 



BRONCHOPNEUMONIA 425 

worse is a favorable indication. Improvement sets in as the cyanosis 
and dyspnea become less intense, the temperature gradually falls, 
while the now effectual cough helps to clear the air passages; the 
child awakens from its lethargy and takes its food more readily. 

The Cough. — The cough is usually intermittent, though sometimes 
it is continuous, dry, harsh, and irritating, loosening as the mucous 
secretion increases. Or it may be entirely wanting for a time, after 
which it is feeble and accompanied by pronounced prostration and 
delirium. As already noted, young children do not expectorate but 
swallow the purulent sputum and consequently often suffer from gastro- 
intestinal disturbances. It is difficult and usually unnecessary to 
obtain any sputum for examination. Vomiting, although rare in the 
beginning, is quite common in the later stage. Diarrhea and tympanites 
also appear at this time, the one exhausting the patient's strength, 
and the other interfering with the unhampered action of the diaphragm 
and thus aggravating the dyspnea. 

The Urine. — The urine as in all fevers contains a trace of albumin, 
a few hyaline casts, and now and then a granular cast, but it clears up 
with the general improvement. 

Respiration. — As restlessness, crying, and coughing completely 
alter the respirations, their real character can be judged only when the 
patient is quiet. They are irregular and frequent, 40 to 60, or more, 
accompanied by a short expiratory grunt or moan. Extreme counts 
of 100 or 120 are probably due to the action of toxins on the respiratory 
centre. Dyspnea exists from the onset, but varies in intensity accord- 
ing to the amount of obstruction offered to the free entrance of air 
into the bronchioles and the alveoli, as well as to the pulmonary 
circulation. It may become so marked, and, with the activity of the 
auxiliary muscles of the soft parts above the clavicle and below the 
ribs, so resemble laryngeal stenosis or diphtheria, that, except for 
the absence of the stridor, one might be tempted to perform intubation 
or tracheotomy. 

Circulatory Organs. — The pulse rate is increased from 120 to 160 and 
more, depending upon the height of the fever, the extent of the 
inflammation, the amount of toxemia, and the condition of the heart. 
An affection of the latter is a most serious complication. As long as 
the pulse continues full and strong, even though it be very rapid, there 
is very little cause for alarm, but when it becomes thready, easily 
compressible, and irregular the outlook grows serious. A marked 
obstruction to the pulmonary circulation causes overdistention of 
the right heart, and the resulting venous stasis manifests itself in 
cyanosis, and swelling of the eyelids, the hands and the feet. 

Temperature. — Except in very debilitated (marantic) children, who 
may have little or no fever, the temperature ranges from 101° to 
105° F., attaining its maximum in a week or ten days and running 
an irregular, markedly remittent, even intermittent course. As a 
rule, it terminates by lysis; a crisis is probable in those cases which 
are due chiefly to the pneumococcus. A relapse causes the tempera- 



426 DISEASES OF THE RESPIRATORY TRACT 

ture to rise again for a few days, after which it gradually returns to 
normal. Though it is true that diagnosis is largely made from the 
clinical picture, nevertheless the physical signs are important con- 
firmatory evidence. 

Inspection. — The character of the breathing alone is frequently 
sufficient for a provisional diagnosis. Symptoms of dyspnea, abnor- 
mal activity of the auxiliary respiratory muscles, inspiratory retrac- 
tion of the soft parts, the peripneumonic groove, progressive cyanosis 
with cold, blue extremities and, finally, signs of more or less pros- 
tration cannot fail to be recognized. 

Auscultation is often puzzling on account of the frequent changes 
noticed from day to day. Usually both lungs are involved but by no 
means equally so. During the early stage, the breathing is often 
harsh and accompanied by medium or coarse rales. After some time, 
fine crepitations of the bronchioles and the alveoli become audible, 
disappearing in one place, reappearing in another, and being irregularly 
distributed in patches over both lungs but principally over the posterior 
bases. Consolidation of larger areas is evidenced by bronchial breath- 
ing and distinct bronchophony, which are brought out more clearly 
on coughing or crying. It is therefore equally important to auscult 
the chest both while the child is breathing quietly and while it is 
crying. Often the heart sounds are heard very distinctly over large 
consolidated patches of the left lung. 

Percussion. — Early in the disease the resonance is not impaired; 
on the contrary the percussion note may be somewhat tympanitic. 
It may, however, be slightly diminished over patches, especially in 
the lower posterior lobes, this impairment becoming more marked 
later when the scattered small areas of consolidation tend to coalesce. 
Real dulness is rare except when larger areas are involved; these then 
give rise to signs similar to those of lobar pneumonia, except that 
they appear later and clear up more slowly. When the right heart 
is embarrassed by obstruction to the pulmonary circulation, its dul- 
ness extends beyond the sternum to the right, and with increasing 
difficulty in breathing the inferior border of liver dulness may be 
found to be very much lowered. 

Diagnosis. — The cough and the changed character of the respiration 
indicate the lungs as the seat of the disease. During the early stage 
it is often not easy to distinguish bronchopneumonia from severe 
bronchitis, since the latter may also begin with a fever of 103° to 104° 
F. This, however, in bronchitis, falls to 100° or 101° F. within twenty- 
four to forty-eight hours and, in addition, only coarse rales are heard 
over the whole chest, while the prostration and all the other symptoms, 
with the exception of the cough, are less severe than in bronchopneu- 
monia. On the other hand, the appearance of fine crepitations, areas 
of consolidation, the bronchial breathing, and bronchophony indicate 
the more serious character of the trouble. A localized bronchitis, 
especially in children under three years of age, and when accompany- 
ing or following measles, whooping-cough, or pronounced rachitis, 



BRONCHOPNEUMONIA 427 

always arouses a suspicion of bronchopneumonia, provided that acute 
pulmonary tuberculosis (particularly the caseous form which affects 
the lower lobe in children) can be excluded. The latter affection is 
rare, but may give rise to exactly the same symptoms and signs 
except that the areas do not shift as in the other forms of prolonged 
bronchopneumonia; it is, however, definitely determined by the finding 
of tubercle bacilli in the sputum and a family history of tuberculosis. 

It is not difficult to differentiate bronchopneumonia from lobar 
pneumonia in typical cases. A large area of consolidation limited to 
one lobe with definite dulness, bronchial breathing, and subcrepitant 
rales usually indicates lobar pneumonia. In bronchopneumonia, 
while the dulness may be wanting, coarse rales are found over the 
larger bronchi and crepitant or subcrepitant rales appear and disap- 
pear over different parts of both lungs. In the many atypical cases, 
where the physical signs are not thus clearly defined, the clinical his- 
tory as to the onset, the course, and the termination of the symptoms, 
may help in the differential diagnosis. In fact, in the very young 
child the diagnosis often rests entirely upon the rapid respirations, the 
cyanosis, and the prostration. When following either simple bron- 
chitis or that complicating the infectious fevers, an increase in these 
symptoms together with a rise of temperature takes place at least 
twenty-four hours before the appearance of the physical signs. The 
occurrence of bronchopneumonia in weakly infants is not surprising, 
but we must look for a special reason when it attacks apparently- 
healthy children. With them it may be preliminary to measles, or it 
may be masking a whooping-cough of pneumococcal or tubercular origin. 

In cases with a markedly remittent temperature and a very slight 
cough, a combination which occurs not infrequently in infants, the 
possibility of primary or secondary malaria can easily be excluded 
by an examination of the blood. Atelectasis is uncommon after the 
fourth month, and congenital atelectasis is often impossible to diagnose 
in vivo. It is seen most commonly in delicate infants who were with 
difficulty resuscitated at birth, and the cyanosis which is a common 
symptom is out of proportion to the findings in the lungs. 

Complications. — Thrush, in delicate infants, and stomatitis in older 
children are quite common, but true gastro-enteritis is not a frequent 
complication of bronchopneumonia. Vomiting and diarrhea, so often 
seen at the onset, are, no doubt, chiefly functional. There is a certain 
amount of emphysema usually present, not marked enough, however, 
to produce any physical signs. An irregular, remittent, or intermittent 
temperature following bronchopneumonia usually indicates some com- 
plication. Pleurisy, usually the purulent type, does not occur as 
frequently as in lobar pneumonia; otitis media is rather common and 
should be looked for if the child shows increased restlessness, irrita- 
bility and sleeplessness in addition to the usual symptoms. Meningitis, 
arthritis, and purulent pericarditis occur but rarely. 

Prophylaxis. — Children should be kept away from persons suffering 
from a cold or a sore throat, since a corvza or bronchitis is easily 



428 DISEASES OF THE RESPIRATORY TRACT 

acquired by such contact, and may, in a delicate child, lead to a fatal 
bronchopneumonia. If catarrh of the respiratory passages occurs in 
spite of all precautions, it must not be neglected. It is of great 
advantage to protect children, at least up to the fourth year, from 
contracting measles or whooping-cough; after this period there is 
less risk of the dreaded complication of bronchopneumonia. No 
doubt it could often be prevented if children convalescing from measles 
or whooping-cough were not allowed out of doors before the physician 
feels satisfied that there is no further danger of pulmonary compli- 
cation. There should, however, be no lack of fresh air. More cases of 
bronchopneumonia formerly followed the infectious fevers, when the 
patients were kept in overheated rooms and in beds loaded with 
blankets, than at present when plenty of fresh air is the rule. While 
primary cases of bronchopneumonia need not necessarily be isolated, 
isolation is certainly advisable when the disease is secondary to infec- 
tious fevers (measles and whooping-cough); these seem to lend it a 
special virulence or infectivity as evidenced during epidemics in 
measles wards, for example. 

Treatment. — There is no specific remedy and the general treatment 
follows the line of other febrile conditions. It requires special care 
because, the disease being protracted and not self-limited, it is a 
matter of the greatest importance to conserve every bit of strength. 
Restlessness, loss of sleep, indigestion, and an increased strain on 
the heart cause so much waste of vitality that it is most essential 
to make the child comfortable, not by drugs, however, but by a good 
sick-room regime. This will influence the course of the disease con- 
siderably and save many lives. 

The room, bared of all unnecessary furniture, should have, first and 
foremost, a constant supply of fresh — not necessarily cold — air. For 
the very young a temperature under 60° F. is hardly of advantage, 
while 70° F. should be the upper limit. As a dry atmosphere is irri- 
tating, it must be moistened from time to time, by means of a spray, 
a croup-kettle, or wet cloths hung up in the room. There is a tendency 
to overclothe the patient; nothing more than a flannel shirt and a 
simple night-dress is required even in winter. When older children 
are given the open-air treatment, under which the sleep, the appetite, 
and the cough often show striking improvement in prolonged cases, 
they of course require more clothing. The patient should not be 
allowed to lie on his back constantly, but should be turned on the 
side or the abdomen several times a day to encourage aeration of the 
posterior parts of the Jungs. It is of the greatest importance to avoid 
overfeeding, or anything (including many of the time-honored expec- 
torants) that might disturb the appetite and the digestion. Food 
should be given in small quantities and in an easily digested form. 
Nurslings should have some water before feedings, and the intervals 
between the feedings should be shortened, and for the bottle-fed the 
milk formula should be reduced in strength. Children, between 
two and five years of age, with poor appetites, are given albumin 



BRONCHOPNEUMONIA 429 

water, whey, meat or vegetable broths, expressed beef juice, or pep- 
tonized milk, and when the appetite improves diluted milk, gruels, 
light puddings, etc., may be added to the list. Under all circum- 
stances boiled water or sweetened lemonade should be freely offered 
and the bowels kept open at least once daily. In order to disturb 
the patient as little as possible, food, medicine, and local treatment 
should be given at one time, with intervals of two and a half hours of 
complete rest. Of all the various remedies used, the most important 
are baths, counterirritants, stimulants, and inhalations of oxygen, 
and of moistened air. The oiled silk and cotton jacket seems super- 
fluous. Although the old method of using the tent and the croup-kettle 
may have been overdone at times, for there is no doubt that a con- 
tinuously moist atmosphere has a depressing influence, still, when 
judiciously used (10 drops of creosote added to 1 quart of water) for 
about thirty minutes every three or four hours, it certainly relieves 
the acute symptoms, especially the irritating cough and the bronchial 
or the laryngeal spasm. 

Counterirritation over the chest is useful in relieving pulmonary 
congestion and marked bronchial catarrh by causing depletion into 
the peripheral bloodvessels. For this purpose the mustard paste 
applied over the chest or the mustard bath, both continued until the 
skin is thoroughly reddened, are equally useful, but a mustard pack 
is more lasting in its effects. This consists of steeping a cloth in one 
quart of water (105° F.) containing 1 ounce of mustard flour, wringing 
it out and wrapping it snugly around the patient so as to cover the 
entire skin surface except the head and the neck. A woolen blanket 
serves as an outer covering and is so adjusted around the neck that 
the irritant vapors of the mustard oil are not inhaled by the patient. 
As soon as the skin is thoroughly reddened — after ten to thirty 
minutes — the child should be washed with plain warm water and put 
into a moist pack for one to two hours and, finally, given a cold 
sponge. In this way the hyperemia of the skin is kept up for a long 
time afterward. The present-day more intelligent use of hydrotherapy 
yields good results, especially when given with as little disturbance 
to the patient as possible. Sponging with cool water, followed by 
light friction with a dry towel, or a chest compress, the water used 
being at room temperature (70° F., or less, for older children), and 
renewed every one to two hours, is always agreeable to a fever patient. 

For infants and delicate children we prefer to induce deep respira- 
tions by applying warm compresses to the chest followed by a very 
short application of cool water. A similar effect can be obtained by 
spraying a little cool water on the shoulders and the back of the 
patient during a warm bath (93° to 95° F.). Hot baths (100° to 104° 
F.), even in the presence of fever, but more especially with cyanosis 
and a cold skin and feeble pulse, are valuable in quieting the patient 
by reducing pulmonary congestion and equalizing the general circula- 
tion. The use of drugs cannot be justified unless clearly indicated 
for the relief of severe symptoms; they are directly injurious if they 



430 DISEASES OF THE RESPIRATORY TRACT 

upset digestion. Usually the temperature does not run so high as to 
require special treatment, but in exceptional cases where it rises above 
105° F., hydrotherapeutic measures prove superior to quinine and the 
coal-tar products; if used at all the latter should only be employed 
to allay irritation and restlessness. 

Inhalations of steam, as in bronchitis, for ten to fifteen minutes at 
a time, hot drinks, etc., promote secretion and relieve the cough; 
but when the latter is painful or incessant a sedative will be required 
in order to secure sleep and to avoid any unnecessary strain on the 
heart. We recommend codeine, 2V S r -> or morphine, -j^ gr., or a Dover's 
powder 1 gr., every three or four hours, for a child over one year of 
age. When the secretion grows excessive, it seems better to check it 
by administering five to ten drops of belladonna than to try to get 
rid of it by emetics. Sooner or later the heart . suffers from the pul- 
monary obstruction, as well as from the prolonged fever and the 
general toxemia, and should be stimulated as soon as a very rapid or 
a soft, irregular pulse shows that such assistance is needed. Tincture 
of strophanthus retards the pulse, while strychnine is indicated with 
an irregular, soft, compressible pulse; both are useful drugs because 
they are easily digested. Caffein, or a 10 per cent, solution of cam- 
phorated oil, or a ytwo solution of adrenalin in 5- to 10-minim doses, 
intramuscularly, is especially valuable for hypodermic medication, 
in spite of the evanescent effect. While the use of alcohol has been 
abused in bronchopneumonia, it is sometimes serviceable when all 
other means fail, and should be kept in reserve for such emergencies. 
The milder stimulants such as broth, beef-tea, tea, or coffee mixed with 
milk can be given quite early and may suffice in the less severe cases. 
Marked cyanosis is temporarily relieved by inhalations of oxygen, 
which may be combined with menthol, turpentine, or bubbled through 
alcohol. Atropine, t ^q of a grain, administered hypodermically, every 
four hours to a child of three years, is useful when the dyspnea and the 
rapid respiration are due to toxic influences on the respiratory centre. 

Convalescence. — Convalescence is often slow. Open-air treatment 
should be kept up during the warm months. If the catarrh does not 
fully clear up, a stay in the country, or removal to a warmer climate 
during the winter is usually of great benefit. Where these privileges 
cannot be enjoyed, iron, arsenic, quinine, or malt extract with cod-liver 
oil should be given as required. 



DISEASES OF THE PLEURA. 

PLEURISY— SEROUS AND PURULENT. 

Inflammation of the pleura occurs hivchildren, as in adults, either in 
the dry, fibrinous form or with an effusion which may be either sero- 
fibrinous or purulent (empyema). Of these the purulent variety 



PLEURISY 431 

demands our special interest because of its comparative frequency 
in children, especially those under five years of age, and because it 
may lead to a fatal issue unless prompt diagnosis — by no mean> always 
easy — points the way for proper treatment. 

Although pleurisy may be caused by an inflammation spreading 
from the ribs, the vertebrae, and the peritoneum, it is not merely a 
local affection but is almost always a sign of a general morbid state. 
In the rare examples in which it apparently results from a chill or from 
exposure, it is, no doubt, really tuberculous or rheumatic in origin. 
It has been observed in sepsis of the newborn, during and following 
the infectious fevers, such as scarlet fever, measles, grippe, whooping- 
cough, diphtheria, and typhoid fever, but the majority of all cases 
occur secondarily to pneumonia and bronchopneumonia. For this 
reason it prevails more often during the cold, damp season, and is 
more apt to affect boys than girls on account of their greater Liability 
to contract pneumonia. Pleurisy is not frequent in infants less than 
six months old, but is quite common between the sixth month and 
the sixth year, and, as a rule, the younger the patient the greater the 
likelihood of its being purulent in character. 

Pathological Anatomy. — Postmortem the pleura may merely show a 
lack of luster, some adhesions either localized or spreading over more 
or less extensive areas, and deposits of fibrin varying from simple 
roughening to a felt-like layer sometimes J to 1 inch thick. In these 
extreme cases, a shrinking of the lung and a corresponding retraction 
of the affected side naturally follow. The effusions differ greatly in 
quantity and also in character in different cases; they may be unilat- 
eral, bilateral, or sacculated, i. e., localized, and shut off from the rest 
of the pleural cavity by adhesions. A large amount of fluid in the 
pleural cavity will push the lung upward, thus assisting its natural 
tendency to recoil and allowing very little possibility for expansion. 
A serous effusion has a light greenish-yellow color; it is clear, or slightly 
cloudy, and contains fibrinous shreds; in favorable circumstances, 
it is capable of being completely absorbed with little diminution of 
the respiratory capacity. Large purulent effusions, however, are not 
absorbed, and an empyema if not properly treated results in pyemia 
or cachexia, unless the pus finds a natural outlet by ulcerating through 
the thoracic wall, or by breaking into a bronchus. While it is true 
that a serous effusion may exceptionally become purulent by second- 
ary infection, an acute pleuritis, as a rule, must necessarily be either 
serous or purulent, according to the predominating microorganism. 
Generally speaking, a thin, yellowish pus indicates a streptococcic 
infection and a thick, pale green discharge a pneumococcic infection, 
though, of course, the naked eye appearances are not very reliable. 
The consistency depends upon the relative proportion of serum and 
pus cells present. 

Bacteriology. — In pleuiisy, pneumococci are usually present; strep- 
tococci and staphylococci are less frequent, while typhoid, colon, and 
influenza bacilli are only occasionally found. Empyema, in 70 to 90 



432 DISEASES OF THE RESPIRATORY TRACT 

per cent, of cases is due to pneumococ6i, either in pure culture, or 
combined with other microorganisms; streptococci predominate in 
5 to 15 per cent., while tubercle bacilli are responsible for only about 
5 per cent, of all cases of empyema in children. 

The amount of fluid varies according to the age and the size of the 
child and the duration as well as the character of the effusion; it is 
greater when the fluid is thin. In children under three years it rarely 
amounts to more than \ to 1 pint while in older patients as much as 
3 or 4 pints is not uncommon. 

Symptoms.— These vary considerably in the different types of 
pleurisy. In a well-marked case, more or less fever, cough, and pain, 
together with respiratory and circulatory disturbances, are present, 
and are not infrequently accompanied by headache, vomiting, and 
constipation. Generally speaking, a baby sick with pleurisy is very 
sick indeed and looks it. As mentioned before, most cases occur 
secondarily to pneumonia or to bronchopneumonia, either during 
their course, thereby greatly prolonging the duration of the fever, 
or — more commonly — within a few days after the crisis or the lysis. 
In these cases the onset is marked by a new rise of temperature up 
to 103° or 104° F., an aggravation of the dyspnea, and the cough, 
often also of the pain, and a pronounced increase in the pulse rate. 
A sudden onset, somewhat resembling that of a milder pneumonia, 
characterizes these comparatively rare cases of primary pleurisy, 
which begin with headache, vomiting, chills and fever, 102° to 103° 
F., and are soon followed by a hacking cough, pain in the chest, and 
shallow, rapid breathing. Occasionally the onset is more lingering 
or gradual in type. The child is ailing for a week or two, with failing 
appetite and a low fever, increasing weakness, anemia, and a slight 
cough. 

When the pleuritic effusion has taken place, the clinical picture 
changes, the symptoms naturally varying with the amount of fluid 
and the rapidity of its accumulation. The patient often lies on the 
affected side, avoids loud crying, is pallid, as a rule, but becomes 
cyanotic when the heart is embarrassed by the fluid. The cough may 
disappear, though sometimes it becomes spasmodic. Breathing is rapid, 
superficial, and increased on the sound side, while the dyspnea becomes 
very apparent on the least exertion in speaking or moving. Often 
there is neither pain nor cough to indicate the seat of the trouble; 
such cases of malaise, feverishness, accompanied by poor appetite, 
coated tongue and restlessness are quite likely to be designated 
"dentition fever." 

Fever. 

Pain. 

Cough. 

Respiration: dyspnea. 

Circulation: cyanosis. 
Fever. — Too much reliance should not be placed on the temperature 
charts, as the fever often runs an irregular and exceedingly variable 



Individual symptoms 



PLEURISY 4:;:] 

course. It is usually high during the first few days, ranging between 
101°, 104°, or 105° F., and in serofibrinous effusion is apt to become 
remittent; during the second or third week it abates as the absorp- 
tion of the fluid progresses. In empyema, the temperature rise is 
usually not quite so high at first, it may be irregular, intermittent, 
or hectic, with night-sweats and rapid emaciation, especially when 
following the exanthemata. In a pneumococcic pleuritis, the tem- 
perature variations do not seem so marked. Unless properly treated. 
the fever may last many weeks; but, on the other hand, it may be 
entirely absent in the later stage. 

Pain* — Pain in the side, aggravated by dee}) breathing and coughing 
and not infrequently referred to the abdomen or the shoulder, is an 
early symptom, and usually disappears with an effusion sufficient to 
separate the pleural surfaces. The affected side may be tender to 
pressure; pain in the right side is due to pressure of a right-sided 
effusion on the liver. 

The Cough. — The short, dry, painful cough, which the child makes 
every effort to suppress, may become less frequent and may some- 
times, but not always, disappear when the effusion is large. 

Respirations. — Respirations are frequent, shallow, often irregular, 
and more or less painful, especially in diaphragmatic pleurisy. Often 
the child lies on the affected side in order to limit its movements 
and allow more freedom of expansion to the sound lung. The pain 
usually diminishes as the extravasation increases, but the shortness 
of breath (dyspnea) becomes more noticeable the more the lung 
recoils (favored by mechanical compression). When the effusion 
advances rapidly, the distress is very marked indeed, while it may 
escape attention when its progress is slow. In empyema the respira- 
tions are always increased to 40 to 70 per minute. The dyspnea 
corresponds to the amount of fluid, but often manifests itself only on 
exertion or by a feeling of fatigue. 

The Circulation. — The pulse is always rapid, 100 to 150 per minute, 
even where there is little or no fever; it becomes still more accelerated 
during the febrile period, or when a large or rapidly increasing effusion 
embarrasses the heart. It then becomes feeble, irregular, and very 
rapid upon the slightest exertion. In addition, venous engorgement 
of the face and the neck may become noticeable. All cases of pleural 
effusion lead to a more or less pronounced anemia; empyema, further- 
more, is usually attended with loss of flesh and prostration, sometimes 
with night-sweats, and, in more chronic cases, a rapidly developing 
clubbing of the fingers accompanied, not with cyanosis, but with a 
peculiar yellowish tint of the skin. 

The Course. — Dry pleurisy clears up within a week, unless due to 
tuberculosis or to pneumonia. Very large effusions may cause cyanosis, 
pulmonary edema, and death if not relieved in time. The acute stage 
of empyema, with loss of appetite, flesh, and strength, and sometimes 
accompanied by hectic fever and night-sweats, lasts about two to 
four weeks. It may be followed by apparent convalescence, during 
28 



434 DISEASES OF THE RESPIRATORY TRACT 

which the patient has little or no fever and seems to be regaining his 
color and strength, but the cough and the rapid respiration and the 
dyspnea reappear on the slightest provocation and give fair warning 
of a false security. If empyema is allowed to become chronic the 
symptoms resemble those of tuberculosis. 

Physical Signs. — The chest signs are essentially the same whether 
caused by a serous or by a purulent effusion. While an appreciable 
amount of free fluid in the pleural cavity of one side is quite easily 
detected, detection is more difficult when the effusion is localized or 
bilateral, or when there has been a previous thickening of the pleura. 
The upper border of the lung, as a rule, remains unchanged, but the 
lower resonant border, retracting from the gradually increasing fluid, 
is highest in the axilla, sloping downward and inward to the sternum 
in front and toward the spine posteriorly. The lower limit of the fluid 
is not identical with the lower border of the normal lung because 
the diaphragm is often elevated even with a comparatively large 
effusion, and becomes depressed only in the late stage when extravasa- 
tion is excessive. 

Inspection. — In addition to the shallow, accelerated, jerky, and 
painful breathing in effusion of appreciable degree, the affected side 
appears larger, the respiratory excursions are diminished and the 
depression of the intercostal spaces is less noticeable. 

In a very marked effusion the signs of severe dyspnea, of expiratory 
distention of the large veins of the neck, the increased measurement 
of the affected side, the displacement of the heart, and possibly an 
elevation of the shoulder, are so obvious as hardly to be overlooked. 

Palpation. — Vocal fremitus, quite apart from the fact that it is 
not easily elicited in young children, is lost or lessened over the fluid; 
respiratory movements are diminished over the affected side and 
increased over the sound one. There may be sensitiveness to pressure 
between the ribs. With a large left-sided effusion the apex beat may 
be palpable at the epigastrium or even further to the right, but in a 
right-sided effusion the apex may be found displaced to the left as far 
as the midaxillary line. 

Percussion. — Percussion is often painful over the affected pleura, 
and often gives much more valuable information than auscultation. 
It should be done lightly as, otherwise, a thin layer of fluid over the 
spongy lung tissue or over the stomach would cause no appreciable 
impairment of the note. With the child in an upright sitting posture 
a dull rather than a flat note is elicited over the fluid, which commonly 
gathers ic the lower and posterior part of the chest, and when encap- 
sulated occasionally in other parts of the ches+. Owing to the gravita- 
tion of the fluid, the upper line of dulness often shifts with a change of 
position; resonance amounting to subclavicular tympany in very 
large effusions is always found directly above the fluid. When the 
latter almost fills the entire side, the dulness may extend beyond its 
border some distance to the sound side — beyond the sternum anteriorly 
and the spine posteriorly. 



PLEURISY 435 

A very valuable sign appreciated by the percussion finger is a peculiar 
board-like resistance, doubly striking in children on account of their 
naturally thin and elastic chest walls. Displacement of the liver 
downward encroaching upon the stomach, but especially on the heart, 
as mentioned under palpation, is almost pathognomonic. Dulness 
on percussion and a board-like resistance are alone sufficient to justify 
exploratory puncture in order to determine the character of the sus- 
pected pleural effusion. 

Auscultation. — As a whole, auscultatory findings are very variable, 
and therefore unsatisfactory and even misleading in infants and chil- 
dren. Early in pleurisy, and again when the fluid is almost absorbed, 
a friction rub may perhaps be heard with inspiration or expiration or 
with both; it is superficial in character and unchanged by coughing. 
Only in rare cases where a large effusion leads to compression of the 
lungs is there sometimes complete absence of voice and respiratory 
sounds. They frequently remain almost normal but are usually dimin- 
ished, distant, and indistinct. Bronchial breathing, although usually 
more feeble and distant over the fluid on deep breathing, is sometimes 
as marked as it is in pneumonia.* It is often heard also along the 
spine and the sternum — an important fact in differentiating the 
condition from pneumonia. Whatever the character of the breath 
sounds on the affected side they contrast markedly with those of the 
healthy lung where they are puerile and harsh (exaggerated). 

X-rays are helpful in locating sacculated empyemas; in a general 
effusion they show the diminished movement of the pleura on the 
affected side and the displacement of various organs. In the interest 
of exact diagnosis and prognosis an exploratory puncture is advisable, 
even though there may be bronchial breath sounds or crepitations 
audible over the area of increasing dulness. The point of choice for 
the puncture is the posterior axillary line — the sixth interspace on the 
left side, the fifth on the right side. When the fluid is localized the 
puncture should be made over the point of most marked impaired 
resonance. With the proper antiseptic precautions, a sterile needle 
is introduced slowly for about an inch, gentle suction being kept up 
all the time. If the needle becomes plugged up on account of its small 
calibre, it may happen that no pus can be obtained; this may also 
occur if the needle is pushed beyond the visceral pleural layer into 
the lung tissue, or if it penetrates an adhesion, or a mass of fibrin, etc. 
The fluid when obtained should be submitted to a bacteriological 
examination. 

Differential Diagnosis. — The diagnosis of pleural effusion in the 
presence of dulness or flatness, and of more or less displacement of the 
heart or the liver, is definitely determined by exploratory puncture. 
This makes it possible to exclude allied conditions, such as unresolved 
pneumonia, pulmonary tuberculosis with extensive caseation, and 
the rare cases of abscess of the lung. The differentiation is more 
difficult in case of subphrenic abscess, of large pericardial effusions, and 
of localized empyema. Again, typhoid fever and malaria may simulate 



436 DISEASES OF THE RESPIRATORY TRACT 

the constitutional symptoms of empyema, but the different physical 
findings and the blood examination hardly leave room for doubt. 

Prognosis. — Spontaneous recovery of empyema cannot be expected, 
although Nature does make an attempt to get rid of the effusion. The 
pus may break through into a bronchus and be coughed up, thus 
giving some temporary relief; or it may be directed externally and 
continue to discharge for many months, the patient finally dying 
from exhaustion, amyloid degeneration, or tuberculosis. In the 
absence of serious complications, such as double empyema, purulent 
pericarditis, meningitis, pyemia, or pulmonary tuberculosis, prompt 
and efficient treatment is certainly very satisfactory; but the final 
outcome will naturally depend upon several other factors. The disease 
is very grave and the mortality is high, especially in hospital children 
under one year of age.' After the second year the prognosis is very 
good, for with early surgical treatment recovery is almost the general 
rule. A delayed operation cannot give as good results on account 
of the greater weakness of the patient and the increasing difficulty 
of proper reexpansion of the lung. In general, the outlook is best 
when the disease is of pneumococcic origin, less so when staphylococcic, 
worst of all when streptococcic. 

Treatment. — Fresh air, sunshine, avoidance of all exertion, are as 
essential here as in pneumonia. Fixation . of the affected side by 
flannel bandages and the application of heat in the form of fomen- 
tations or turpentine stupes, or of mustard paste, usually suffice for 
the relief of pain. However, sometimes opiates (codeine, morphine, or 
paregoric) are necessary to prevent loss of sleep from excessive 
coughing. 

During the febrile stage, dry and serofibrinous pleurisy are treated 
alike by a fever diet and rest in bed. As soon as there is a tempera- 
ture or there are signs of an effusion, the child must neither sit up nor 
exercise its arms and its lungs more than is absolutely necessary. 
When a serous effusion has occurred, the diet adapted to the dimin- 
ished digestive capacity is- (for children over two years of age) usually 
restricted principally to solids — bread and butter, eggs, puddings, 
beef -juice, malt extracts, and very little milk; although it is very 
doubtful whether a diminution of liquids influences the absorption 
of the fluid. This may be facilitated to some extent by external appli- 
cations of heat, counter-irritants, ointments containing 10 to 16 per 
cent, of guaiacol, hydrargyrum or iodine, and by purgatives and diu- 
retics. It is always wise to prescribe some heart stimulant, either 
digitalis or strophanthus. Sodium salicylate, or aspirin (5 grains 4 
times a day) in sugar water, is best given in the early stage, and 
potassium iodide later on when absorption has begun. 

Evacuation of the effusions during the acute stage is contraindi- 
cated, except when breathlessness, cyanosis, and cardiac embarrass- 
ment make it imperative; but if the fluid does not diminish within 
two to three weeks it should be removed (except in tuberculosis) by 
siphonage or aspiration. Drainage can be secured either by simple 



PLEURISY 437 

incision after the site of the pus has been explored with the needle or 
by resection of a portion of one or of several ribs. Simple incision 

is more quickly done. It requires only local anesthesia and usually 
proves successful, especially in babies under two years old. An 
incision about two inches long is made in the fifth or sixth interspace 
in the middle axillary line, close to the lower rib through the inter- 
costal muscles. After opening the pleura, the pus is allowed to escape 
slowly, large coagula being removed with forceps, and a >hort drainage 
tube of large calibre for two smaller ones side by side if the ribs are 
close together) is inserted and fastened with large safety pins. The 
whole is covered by a thick aseptic dressing which must be renewed 
or reinforced when it becomes saturated. The drainage tube should 
be removed as soon as the discharge grows serous. The wound then 
closes in a short time, and is usually completely healed within three to 
seven weeks after operation. 

Resection of a part of one or of several ribs is the best means of 
ensuring thorough evacuation and also rapid recovery. Only light, 
general narcosis is necessary. An incision, two to three inches long, 
is made directly over the eighth or ninth rib, in the posterior axillary 
line; the periosteum being stripped back, about two inches of the rib 
are cut away with bone forceps or with special rib-shears. On open- 
ing the pleura, pus flows out with each respiration, and more rapidly 
with coughing. Some surgeons insert the finger to remove thick masses, 
or break down adhesions in order to empty any existing pockets of 
pus, and even advise irrigation of the pleura with saline solution. 
However, it is not necessary to empty the cavity completely, for what 
remains is often rapidly absorbed, but it is essential that the with- 
drawal should be gradual, and that it be stopped with the appearance 
of violent coughing, weakness, fainting, or bleeding. 

If the effusion were allowed to stay from six to eight weeks, thicken- 
ing of the pleura, adhesions, and impeded expansion of the lungs would 
probably result. Therefore, when repeated tapping in serous effusions 
effects no cure, incision and drainage become necessary. The point 
of choice for paracentesis is in the sixth or seventh interspace near the 
middle or posterior axillary line or at the place of greatest flatness. 
If there is any uncertainty as to the exact site of the fluid, this should 
be ascertained by puncture. With the proper antiseptic precautions 
and with the child in a sitting posture, a trocar of T V-inch calibre is 
quickly introduced for about an inch close to the upper edge of the 
rib. While an effusion of recent date evacuates itself, unless fibrin 
shreds obstruct the opening, very little or nothing at all will flow out 
spontaneously in a chronic case on account of the insufficient pressure, 
and removal by siphon or aspiration may become necessary. The 
small opening is subsequently closed with collodion. 

The fluid in young children is usually purulent or seropurulent. 
The only satisfactory treatment for this is surgical evacuation of the 
pus as soon as diagnosis has been made. A short delay may be per- 
missible only in a small empyema following pneumonia when con- 



438 DISEASES OF THE RESPIRATORY TRACT 

valescence is otherwise satisfactory. Aspiration is insufficient except 
as a temporary measure to relieve distress, and as a preliminary reduc- 
tion of excessive effusion. 

During convalescence the patient should live in the open air but 
should avoid any excessive use of the chest and the arms. The diet 
should be carefully regulated, and malt extract with iron, cod-liver 
oil, and arsenic administered in proper moderation. Later, breathing 
exercises, varied so as to take the fancy of the child, such as blowing 
a trumpet, or soap-bubbles, or fluids from one bottle to another, are 
advisable as aids in successfully reestablishing the expansion of the 
chest. After six months the orthopedic surgeon should be consulted 
for any chest and spinal deformity, although breathing and gym- 
nastic exercises properly directed and intelligently carried out may do 
much to diminish such deformities. 

Bilateral empyema is rare. If general, on both sides, it is wise to 
relieve strain on the heart by preliminary aspiration followed in a day 
or two by draining the left, and later the right side. In chronic 
empyema more extensive operations, such as advised by Estlander 
Schedes, may become necessary, or even decortication of the thickened 
visceral pleura may have to be resorted to. Summing up, one would 
say that for the successful management of empyema it is essential 
to diagnose it early, to establish prompt and efficient drainage, and 
to pay particular attention to the after treatment. Failure is due to 
either delay, to thick adhesions, to inefficient drainage, or to the 
formation of a persistent sinus. 

REFLEX COUGH. 

A cough, strictly speaking, is always reflex in origin; but, for the 
sake of convenience, we will group under this heading all those clinical 
varieties of cough which, because they furnish no obvious sign of 
inflammation of the larynx, trachea, bronchi, lungs, or pleura, are 
supposed to be due either to vague stimulation in the mouth, throat, 
stomach, or ear, or to irritation of other organs. It is not an affec- 
tion of early infancy, but quite frequently attacks older children. 
Cough is most common in that form of postnasal catarrh which is 
associated with enlarged tonsils and adenoids. Mucus or mucopus 
accumulations in the nasopharynx excite a dry, tickling cough which 
usually comes on as soon as the child lies down (and sometimes only 
then), and is thus apt to disturb the sleep for hours. It may last for 
many months, especially in winter. 

Similar symptoms may be caused by an elongated uvula, or in rare 
cases, by cerumen impacted in the external auditory meatus. In 
mitral disease, probably because of the resulting pulmonary congestion, 
and in pericarditis, a dry hard cough often makes the patient very 
uncomfortable. 

About the time of puberty, and frequently associated with anemia, 
chorea, or extreme nervous irritability, a cough may spring up which 



ASTHMA 439 

may be either of the ordinary type or a curiously monotonous one; 
it is increased by exercise, and ceases during sleep. There is neither 
pain, nor expectoration; the onset and the termination may be either 
gradual or sudden, while relapses are frequent. 

Periodic attacks of a brassy cough may occur regularly every night 
for months, the paroxysms sometimes becoming so severe as to resemble 
whooping-cough, except for the almost complete absence of vomiting. 
These paroxysms are ascribed to an irritation of the pneumogastric 
nerve or its branches, due to the pressure of enlarged lymph nodes 
surrounding the trachea and the large bronchi. This glandular 
enlargement may be present in Hodgkin's disease, and in lymphatic 
leukemia, or it may follow various pulmonary affections, but in many 
cases it is really the primary focus of tuberculosis. 

The patients sometimes seem the very picture of health; but ordi- 
narily long-continued loss of sleep tells on the general health, and 
when the enlargement is part of a tuberculous process the child is 
apt to be delicate, irritable, and easily fatigued, while the appetite 
is failing or capricious. The patient complains of interscapular back- 
ache, or ill-defined pain within the thorax, or sharp and lancinating 
pain brought on by deep inspiration or by violent exertion. The 
superficial thoracic veins may be dilated. Usually there is some 
expiratory dyspnea, and not infrequently an increased sensitiveness 
to cold, especially in the region of the shoulder. A similar cough has 
been observed in connection with abscesses of the posterior medias- 
tinum, and in Pott's disease. 

Symptoms. — In all of these cases it is chiefly the cough which excites 
concern. This grows worse or occurs only at night, and is liable to 
become paroxysmal, the attacks coming on rather regularly. The 
general health may not be affected except for the disturbed sleep. 

Diagnosis. — A reflex cough should not be diagnosed lightly. By 
a thorough examination of the ears, the nose, and the throat, as well 
as the heart, the lungs, and the stomach, in conjunction with careful 
observation of the general condition, it is often possible to ascertain 
its precise cause. X-rays are of great service in cases where enlarged 
lymph nodes are suspected, as after measles, pertussis, repeated attacks 
of bronchitis, or in patients with tubercular antecedents. 

Treatment. — It is obvious that neither opium, nor inhalations, nor 
expectorants will effect a cure. The underlying cause must be treated. 
If this cannot be detected and the condition seems purely nervous, 
small doses of the bromides and of antipyrin may be given at bedtime 
to relieve the cough. 

ASTHMA. 

Excluding cases of mere dyspnea due to cardiac or renal diseases, 
two chief types of asthma are met with in children; the first, the 
spasmodic or true bronchial variety, resembles that of adults, and is 
characterized by paroxysms of expiratory difficulty, the respiratory 
system remaining apparently normal during the intervals. It is only 



440 DISEASES OF THE RESPIRATORY TRACT 

exceptionally observed in children under four years of age, but seems 
not so uncommon from the seventh or eighth year up to puberty. 
The second, the catarrhal type or so-called asthmatic bronchitis, 
differs from the former variety in the increased amount of bron- 
chial secretion and in the character of the dyspnea, the paroxysms 
being preceded, associated, or followed by bronchitis. It is not quite 
so rare in infants as the first type, and is also rather commoner in 
older children. They may suffer from one or several attacks during 
the year, and are liable to be somewhat short of breath during the 
intervals. It may be said, in passing, that undoubted cases of hay 
asthma, occurring especially during hot and protracted summers, have 
been observed as early as the fourth year in children of neuro-arthritic 
families. 

Etiology. — The pathogenesis in the child is no doubt essentially 
the same as in the adult; that is, there exists a neurosis of the respira- 
tory system, manifested by paroxysmal spasms of the respiratory 
muscles, combined with hypersensitiveness, temporary vasomotor 
paresis, and, perhaps, an abnormal secretion of the respiratory mucous 
membrane. These diverse factors probably cause a temporary nar- 
rowing of the lumen of the bronchial tubes. Heredity plays an impor- 
tant role, there being usually a family history of various neuroses, 
gout, eczema, and neuro-arthritis. The poorer classes are relatively 
seldom affected. Dry climates yield the smallest percentage of cases. 
When an attack has once occurred, other paroxysms are readily induced 
by central or by peripheral reflexes. While psychic factors, such as 
fright, emotion, and excitement, are only occasionally responsible for 
an attack, one may be easily induced by any local irritation of the 
nose, the pharynx, or the bronchial mucous membrane, due to inflam- 
mation caused either by the inhalation of irritants, such as dust, pollen, 
gases, certain animal emanations, or to sudden changes of climate or 
of weather conditions. Furthermore, disturbances of the gastro- 
intestinal tract and enlarged bronchial glands also act as exciting 
factors in susceptible children. These are usually delicate, nervous, 
irritable, and anemic, suffering from eczema, from chronic urticaria, 
and hypertrophy of the tonsils and adenoids, though the overfed 
child is by no means exempt. The symptoms of spasmodic or true 
bronchial asthma in children do not differ essentially from those in 
adults. There is a periodic, urgent, and usually sudden dyspnea. 
The child, apparently well, awakens in a fright a few hours after 
retiring, it has a sense of impending suffocation, looks anxious and 
pale, is more or less cyanotic, restless and rigid, or sits up in bed with 
staring eyes, head thrown back, shoulders raised, and its little hands 
clinched, to all appearances fighting against a distressing dyspnea. 

The breathing is slow and labored, the shallow inspirations are fol- 
lowed by a pause and prolonged expirations, while both are accom- 
panied by wheezing sounds, often audible over the entire room. The 
skin and the extremities feel cold and clammy, the pulse is feeble, 
very rapid, and often irregular. In a typical case there is no hoarse- 



ASTHMA 441 

ness, or fever- the temperature may even he subnormal in prolonged 

paroxysms and the cough, if present, is infrequent, dry, and short 
in character, bringing up a mucous expectoration. This contains 
Charcot-Leyden crystals, Curschmann's spirals, and many eosino- 
phils. The paroxysms last several hours, occasionally several days: 
they subside slowly, as a rule, hut sometimes subsidence is abrupt, 
ending with a fit of coughing or vomiting. Considerable exhaustion 
usually follows but the little patient seems healthy in the intervals, 
which may last for weeks or months, depending upon the exciting 
cause. On the other hand, the paroxysms may recur at the same 
hour for several successive days; if at all severe, they naturally 
impair the health. Their severity varies just as do their duration and 
frequency, some children suffering from periodic attacks of musical 
rales for a few days at a time without any apparent dyspnea. 

The type of asthma called spasmodic bronchitis differs from the 
above mainly in the amount of bronchial secretion and the presence 
of fever. It develops during and after an attack of nasal or bronchial 
catarrh, or follows measles or whooping-cough. The paroxysms usually 
come on at night, they vary in frequency, and are characterized by 
an increasing dyspnea, a feeble pulse, and dry rales. After two or 
three days the child appears perfectly well except for a few rales, and 
perhaps a slight cough. During an attack the thorax is held in the 
position of full inspiration with the diaphragm depressed and the 
respiratory muscles contracted. Only a slight recession of the soft 
parts is visible during inspiration. Diffused loud wheezing and rales, 
which at first are dry, then moist, and later mostly expiratory, obscure 
the vesicular murmur. In prolonged cases a hyperresonant percussion 
note reveals emphysema, which in children rapidly becomes extreme, 
but quickly subsides unless protracted by frequent and prolonged 
paroxysms. In asthmatic bronchitis there is practically no hyper- 
resonance but inspiratory recession of the soft parts and lowering of 
the ribs become marked. Many fine rales are heard at the bases. 

Diagnosis. — The special diagnostic features of asthma are: sudden 
onset, recovery when the symptoms are apparently most alarming, 
the absence of fever, and recurrent attacks of inspiratory dyspnea 
out of proportion to the physical signs. With these in mind, it should 
not prove difficult to differentiate the condition from cardiac, renal, 
or diabetic dyspnea. Enlargement of the thymus or the bronchial 
glands, as an etiological factor, can best be excluded by an x-ray 
examination. The dyspnea of retropharyngeal abscess, or of laryngeal 
obstruction, and of inflammatory affections, is decidedly inspiratory, 
while the difficult breathing of hysteria, though it may occur in 
paroxysms, does not cause distress. 

Prognosis. — The prognosis is the more favorable the shorter the 
duration, the younger the patient, and the less pronounced the heredi- 
tary taint. A cure mav be effected by the removal of the local exciting 
cause, or by a change of climate. Towards puberty an abatement and 
even the disappearance of the attacks is not infrequently observed. 
With a poor heredity, a predisposition to true bronchial asthma may 



442 DISEASES OF THE RESPIRATORY TRACT 

last for a lifetime, and may gradually lead to emphysema and 
embarrassment of the right heart. 

Treatment. — The importance of preventing an attack by proper 
hygienic measures, rather than by relying upon means simply to relieve 
or to abort it, hardly needs emphasis. Everything should be done 
to remove the exciting cause and to improve the general health and 
the underlying nervous condition. Systematic breathing exercises 
are of great value. Sometimes a radical change of climate may be 
necessary. The diet must be carefully regulated; special attention 
should be paid to the evening meal, which should be light and taken 
sufficiently early to insure an empty stomach on retiring. While no 
drug has proven a specific for all cases, 3 to 5 minims of a 1 to 1000 
solution of adrenalin chloride given intramuscularly often affords 
prompt relief; inhalations of nascent oxygen, or internal doses of 
cocain hydrochlorate and apomorphin sometimes cut short the 
paroxysms. Expiratory pressure on the thorax is also helpful. Potas- 
sium iodide is of real value when administered regularly for periods 
of from four to six weeks, and interrupted by a course of Fowler's 
solution for a fortnight. In certain cases hypodermics of morphine 
and atropine may be necessary during an acute attack. 

ABSCESSES OF THE LUNG. 

In fatal cases of pyemia and of bronchopneumonia, multiple small 
abscesses are found postmortem, while tuberculous cavities, varying 
greatly in size, are either single or multiple. A larger, single, non- 
tuberculous abscess is of rare occurrence in children and is mostly 
due to staphylococcic or to streptococcic infection; it may follow 
influenza, or pneumonia, or it may result from the aspiration of a 
foreign body, or occasionally from the breaking down of a caseous 
bronchial gland. The physical findings are rather confusing, resem- 
bling those of effusion as well as of consolidation; the exploring needle 
may, or may not, demonstrate the presence of pus. 

Symptoms. — The symptoms in a large pulmonary abscess are similar 
to those of empyema — an irregular hectic temperature, ranging between 
99° to 102° F., sweats, progressive emaciation, and marked leukocytosis 
■ — so that a differential diagnosis of encapsulated empyema, or of 
gangrene, or of a bronchiectatic cavity is often difficult. The abscess 
may cause an empyema either by breaking into the pleural sac or by 
opening into a bronchus and thus lead to a spontaneous cure. 

Treatment. — The treatment is practically that of empyema — 
incision after exploratory puncture, drainage, and the very best after- 
care. The pleura is usually adherent, but, if not, an adhesion may be 
artificially produced by packing the wound. 

GANGRENE OF THE LUNG. 

This disease, due to anaerobic bacteria, is rare in children and seldom 
diagnosed during lifetime. It affects only weakly children in the 



ACQUIRED ATELECTASIS, OR PULMONARY COLLAPSE 443 

course of bronchopneumonia, measles, typhoid fever, tuberculosis 
of the lungs, and of the bronchial glands, or it may follow aspiration 
of a foreign body (especially after laryngeal diphtheria), or septic 
embolism or thrombosis originating in distant parts of the body. 

Pathological Anatomy. — The lower lobes are usually affected. The 
process is generally a diffuse one, with small, grayish-green scattered 
areas; only exceptionally does it involve a whole lobe or an entire 
lung. These foci are often wedge-shaped with their bases directed 
towards the outer surface of the lung, indicating a thrombotic or 
embolic origin. They may soften later on when they emit a charac- 
teristic gangrenous odor, and often produce large cavities with ragged 
necrotic walls, partially rilled with fetid pus. 

Symptoms. — The constitutional symptoms depend to a certain 
extent upon the disease of which the gangrene is a complication; 
they usually resemble those of a typhoid state. The peculiar 
gangrenous odor of the breath if associated with a dirty green, or a 
sanguineous expectoration that contains necrotic lung tissue separable 
into three layers, is an unfailing diagnostic indication, but death 
often ensues before active decomposition and sloughing in the lungs 
has taken place. The physical signs are those of bronchopneumonia. 

Prognosis.— A fatal termination is the rule, although modern surgery 
has several cures to its credit. 

Treatment. — Medicinal treatment should be directed toward main- 
taining the strength of the patient by stimulants and proper feeding, 
and toward arresting the process by inhalations of antiseptics and 
the administration of the oil of creosote. 



ACQUIRED ATELECTASIS, OR PULMONARY COLLAPSE. 

Pathology. — This is distinct from the congenital form, inasmuch as 
the lung had expanded after birth. It is not infrequently seen in 
young children. It may result from pleuritic or pericardial effusions 
so compressing portions of the lung that, although the bronchi remain 
open, the alveoli collapse; after a certain time tissue alterations 
occur which make then reexpansion difficult, or even impossible. 

Similar changes take place when a bronchus is blocked, for instance, 
by a foreign body; in time the air beyond the obstruction becomes 
absorbed, and that part of the lung collapses; finally, atelectasis may 
be acquired by marantic, or greatly debilitated children with feeble 
inspiratory force; this is especially the case in rickets, where weak 
musculature and very flexible ribs interfere with thorough aeration 
of the lungs. 

Symptoms. — The symptoms are more or less marked, and resemble 
those of the congenital form. Rapid superficial respiration, inspira- 
tory dyspnea, and cyanosis of varying degree, with a feeble vesicular 
murmur, and normal or even subnormal temperature point strongly 
to atelectasis. 

Treatment. — The treatment follows the principles laid down for the 
congenital form of the disease. As a prophylactic measure, all young 



444 DISEASES OF THE RESPIRATORY TRACT 

infants should be taken up, or turned over on the abdomen, several 
times a day. This is especially necessary if the child is suffering from 
rachitis. 

EMPHYSEMA. 

The peculiar structure of the lung favors the occurrence of acute 
emphysema in young children, and especially so if the patient is 
rachitic, but most cases of emphysema subside quickly after the termi- 
nation of the primary disease. Usually three forms are differentiated. 

In one, called compensatory, the alveoli of certain portions of the 
lung become overdistended from an effort to compensate for deficient 
aeration of other parts; as, for example, in pneumonia, tuberculosis, 
and when there is diminished expansion caused by adhesions, thickened 
pleura, or external pressure. 

The second form causes the same pathological lesions, but depends 
more upon an obstruction to expiration or a prolonged cough — the 
vesicles becoming distended because the air cannot readily escape — 
as seen in pertussis, bronchitis, and all forms of laryngeal stenosis. 

A third kind, so-called interstitial emphysema, in which air from 
ruptured air vesicles escapes into the interstitial and even subcutaneous 
tissues, is very rare indeed. 

Pathological Anatomy. — The adult form of more or less general 
emphysema with permanently enlarged alveoli and dilated right heart 
is hardly ever seen in young children. The thorax is not barrel-shaped, 
but may be abnormally full just beneath the clavicle. On opening 
the chest, the lung does not readily collapse. Certain localized areas, 
principally around the apices and anterior borders, are raised, feel 
velvety, look whitish-yellow, and crepitate under the finger. Usually 
only a few septa are ruptured, but in more severe cases (pertussis) 
blebs of fairly large size may be seen. 

Symptoms.— The signs in cases of emphysema which occurs in acute 
pulmonary disease are not very distinctive. There may be hyper- 
resonance over the emphysematous areas, prolonged expiration, and, 
perhaps, diminished tactile and vocal fremitus. The ordinary dulness 
of heart, liver, spleen, and consolidated lung is not infrequently masked 
or diminished by overlying emphysematous lung tissue. The symp- 
toms are principally those of the underlying disease, and on its sub- 
sidence disappear in a comparatively short time. Fat, pasty-looking 
children with flabby musculature are especially prone to the affection. 

Treatment. — The treatment resolves itself chiefly into that of the 
primary disease; i. e., bronchitis, asthma, pertussis, etc. Outdoor 
life is essential, but undue exposure must be avoided. Both country 
and mountain air offer undoubted advantages. During convalescence, 
a course of arsenic, interrupted after a few weeks by the administration 
of small doses of the iodides, certainly does good. In the rare subcu- 
taneous forms of emphysema, the skin is punctured, the air pressed 
out, and mechanical means — that is, compression of the chest during 
expiration — may be used to relieve the dyspnea. 



CHAPTER XV. 
DISEASES OF THE HEART. 

( CARDIOVASCULAR diseases are more common in children than is gener- 
ally assumed, often beginning in early childhood, especially among 
the poorer classes. They are less complex and appear in fewer forms 
than in the adult, but are by no means less severe. In order to under- 
stand and to differentiate diseases of the heart, the physician must 
have accurate knowledge of the anatomy and physical peculiarities 
of the circulatory apparatus, both in infancy and childhood, and of 
its mode of development. 

As the primary cardiac tube develops, it is gradually transformed 
by constriction, sigmoid twisting, and the formation of internal septa, 
into the fetal heart. Fetal circulation differs chiefly from the circu- 
lation after birth in the fact that, with the exception of the umbilical 
veins, which carry pure arterial blood, most of the bloodvessels con- 
tain a mixture of arterial and venous blood; that is, the systemic 
and the pulmonary circulations have not as yet become distinctly 
established. 

The Heart. — In children the organ is relatively larger than in 
adults, as are also the lumina of the bloodvessels. As a natural con- 
sequence, the blood-pressure in early childhood is lower than in adults, 
and increases toward puberty as the relative narrowness of the arterial 
system increases. 

At birth the heart weighs from one-half to one ounce, doubles this 
weight by the end of the second year, increases to two and one-half 
ounces by the fifth year, and to about five ounces by the fourteenth 
year; thus the most rapid increase is in the first year and toward 
puberty. 

In this connection it is interesting to note that, while the total 
body weight of the adult is twenty times as great as at birth, the 
adult heart is only fifteen times its original weight; also that, while 
the walls of the right and left ventricles are in early infancy almost 
equal in thickness, the left is twice as thick as the right toward the end 
of the sixth year. 

The circumference of the heart increases but little during the first 
five years, but the heart muscle grows stronger; therefore there is no 
corresponding increase in the size of the cavities. After the fifth year, 
however, the increase in the size of the cavities corresponds more 
nearly to the increase in the size of the organ. ^Yhile the total size 
of the heart becomes twelve times as great between infancy and ado- 
lescence, the aortic orifice becomes only three times as large as at birth. 



446 DISEASES OF THE HEART 

In fact, the obstacles which the cardiac muscle has to overcome find 
expression in a gradual rise of the blood-pressure which, in the first 
and second year, reaches 80 to 85 mm.; at the seventh year is between 
90 and 95 mm.; from the eighth to the tenth year is 95 to 100 mm.; 
and thence to puberty is 100 to 110 mm. 

The Pulse. — In childhood the pulse is very rapid, the number of 
beats varying from 120 to 140 at birth to 100 to 120 at the end of the 
first year, then diminishing by about five beats a year until the tenth 
year, when the average is about 80 for boys and 90 for girls. Both its 
rate and regularity are influenced by even trivial causes, such as cry- 
ing, excitement, accelerated respiration, and sleep. 

The Apex Beat. — The location of the apex beat varies not only in 
different children, but also in the same child at different times, follow- 
ing no definite rule. Generally speaking, it is a little higher in infancy 
than it is later. Up to the fourth year it is found just outside the nipple 
line; from the fourth to the seventh year at the nipple line; subsequently 
a little lower, but well within the mammary line, according to the shape 
and development of the chest, and the position the child is in. It moves 
laterally as the child turns, and sinks when it assumes the erect or hori- 
zontal posture. Up to the fifth year it is usually found in the fourth 
interspace, and later sinks to the fifth. 

In recent years great progress has been made in the study of func- 
tional disorders and diseases of the heart in childhood. But, in order 
to investigate these with an open mind, one must disregard experience 
gained from the study of the adult heart, upon which degenerated 
arteries, chronic bronchitis, emphysema, chronic renal disease, and 
poisons (alcohol and syphilis) exert such a powerful etiological action, 
these factors being practically non-existent in childhood, many forms 
of cardiac disturbance at this early age being non-organic in nature. 

This period of life has its own problems and peculiarities. Not only 
is the vasomotor tone of the arteries unstable, but the nerve-control- 
ling mechanism, central as well as peripheral, and even the heart itself, 
show great instability. They are readily disturbed because not yet fully 
developed. We must therefore allow ourselves considerable latitude 
when considering physiological cardiac manifestations, and be cautious 
in regarding them as pathological. 

Even real lesions which affect the auricular and ventricular muscular 
tissue may, if limited in extent, be completely compensated by normal 
growth. In discriminating between those signs which are of no sig- 
nificance and those which point to actual disease, it is extremely impor- 
tant to consider what the heart is capable of doing when the child is at 
rest, and also when exercising, rather than the sounds produced. While 
in later life the changes produced by heart disease are degenerative 
and fibrotic in nature, in the early stages of heart disease in children 
these changes are inflammatory in nature, and do not, as a rule, pro- 
duce dyspnea, cough, or edema. 

General Symptomatology and Diagnosis. — The symptoms of cardiac 
disease depend chiefly upon the anatomical structure and physio- 



MURMURS 447 

logical function of the organ, and the nature of the morbid process 
affecting it. Although the symptoms are less complex than in adults, 
since secondary conditions in remote regions (such as dropsy or con- 
gestion of parenchymatous organs) are usually lacking in early child- 
hood, yet the physical examination calls for greater precision, since 
everything depends upon accurate observation, and the chief difficul- 
ties are in deduction, not in method. In regard to the mode of examin- 
ing the heart it may be well, however, to state that in the case of strug- 
gling children it is best to use the ear, and, instead of a stethoscope, a 
phonendoscope which, being flat, can easily be placed in the axilla or 
under the back without raising the child from the bed. 

The pulse gives us little information, there being neither arterial 
degeneration, marked irregularity in rate, nor variability in strength; 
but the continuous rapidity and progressive diminution in volume in 
acute pericarditis and the arterial spasm and heightened blood-press- 
ure in renal disease are quite significant. Disturbance of rhythm is 
not at all uncommon; indeed, arrhythmia may be said to be almost 
physiological in infancy, especially during sleep. It is also apparent 
after infectious diseases, and in the early stages of tuberculous men- 
ingitis may be marked, but is of significance only in diphtheria. In 
older children the sole assignable cause for it is a neurotic disposition. 
In contradistinction to arrhythmia due to myocarditis, the harmless 
arrhythmia of childhood disappears with increase in the pulse rate 
due to fever or exertion. 

Transitory tachycardia, which appears during the course of fevers 
and is readily produced by excitement, is most marked in neurotic 
children. Even in the older neurotic child, excitement and exertion 
often make the pulse extremely rapid and compressible; this, however, 
is of no significance, even if accompanied by a diffuse apex beat. 
Accelerated pulse rate induced by moderate exertion, and not abating 
after three minutes of rest, suggests weakness of the heart muscle. 

Paroxysmal tachycardia, in some cases hereditary, has been observed 
in older children. Although not amenable to treatment, it usually 
subsides under hygienic management and judicious exercise. Hoch- 
singer mentions a permanent tachycardia due to the pressure of 
enlarged bronchial glands upon the pneumogastric nerve. 

Bradycardia is common in infants. In older children it is frequently 
associated with arrhythmia, and is most likely to occur in diphtheria, 
but may be pronounced in infectious myocarditis. In rare cases, it 
accompanies appendicitis: 

MURMURS. 

There are cardiac disturbances which produce no changes that can 
be detected by percussion, these being apparent only on auscultation. 
In children, as a rule, cardiac sounds are loud; only in very young 
infants are they dull, or even impure. 

Bruits, or murmurs, are frequently found, and during the first two 
years of life they usually indicate congenital disease of the heart. At 



448 DISEASES OF THE HEART 

this early age acquired as well as accidental murmurs are rare. Albu- 
minuria does not always signify renal disease; neither does a cardiac 
murmur in itself necessarily mean heart disease. The important thing 
is to decide whether the working power of the heart is, or is likely to 
be, affected, and to decide this question a clear distinction must be 
made between organic disease in childhood (congenital or acquired 
valvular, or acquired pericardial) and so-called functional or accidental 
(extracardial or cardiopulmonary) disorder. Functional murmurs 
are very common in childhood, especially during school age. In school 
children one often finds a soft systolic murmur over the pulmonic 
area. Some observers with modern sensitive stethoscopes may find 
them in even a great number. When faint they are, however, more 
interesting to the observer theoretically than of practical importance 
to the patient. While there is no doubt that distinct murmurs of this 
type have been found even in children under two years of age, they 
are, as a rule, rare before the fourth year. 

Three types of functional murmurs may appear between early 
life and puberty; (1) a pulmonary systolic murmur, so common that 
it may be considered almost physiological ; (2) a cardiopulmonary mur- 
mur; (3) a systolic murmur of cardiac atonicity which, although pro- 
duced at the valve, does not signify cardiac disease. In the other 
types, accidental murmurs are probably caused by the more rapid 
circulation together with decreased viscosity of the blood. 

1. Pulmonary Systolic Murmurs. — In this type of murmur the 
maximum intensity is between the second and third costal cartilages 
close to the sternum, and is either limited to this area, or, in exceptional 
cases, may extend a few inches to the left, sometimes being faintly 
audible even at the apex. This bruit with an accentuated second pul- 
monic sound is almost physiologic in children, and usually disappears 
at puberty. Its origin is, no doubt, at the pulmonary valve, and it is 
probably due to the rush of the blood through a narrow ostium into 
the relatively wide pulmonary artery. The murmur, itself, may be 
very distinct, but it is always soft, blowing, and short, and follows 
closely upon the first sound. It is not accompanied by any symptoms 
of heart disease, and has no bearing on the future health of the child. 
It should be differentiated from a congenital pulmonary murmur, which 
is usually rougher, more rasping, and of longer duration, and is often 
accompanied by dilatation of the right ventricle and weakening of the 
second pulmonic sound. 

2. Cardiopulmonary Murmurs. — These murmurs are extracardiac in 
origin, and are caused by changes in the lungs which occur during the 
systolic contraction of the heart. Whether the murmurs are the result 
of aspiration of air, friction of the lungs and the heart, or the simul- 
taneous vibration of the lungs and heart, has not been fully explained. 
The bruit varies during the respiratory movements, being intensified 
at inspiration, diminished at expiration, and disappearing when breath- 
ing is suspended. It is usually heard between the apex and the ensi- 
form cartilage, but may vary with the child's position and the rate of 



MURMURS 44!) 

the heart; it is always systolic in time, soft and superficial in character, 
and in rare cases only is accompanied by a whiffing sound during the 
diastole. It not infrequently diminishes or disappears altogether 
under firm pressure of the stethoscope on the elastic chest wall. For- 
tunately, neither the patient nor his heart is affected, no symptoms 
are produced, and it is of no prognostic significance. 

3. Intracardiac Murmurs. — Presumably valvular in origin, these 
murmurs may occur without the existence of any organic lesion, and 
are probably due, in part, to temporary insufficiency of either the car- 
diac muscle or the papillary muscles of the mitral valve, this causing 
reflux of blood with or without a systolic murmur, the mitral valves 
themselves remaining perfectly intact. A similar condition is often 
found during and after specific fevers, and disappears during con- 
valescence. Both of these murmurs are probably due to atonicity 
of the cardiac muscle. The former appears in overgrown, neurotic 
girls, and passes away after rest or, in some children, on taking active 
exercise. 

Anemia, in itself, cannot be considered the sole cause, because many 
anemic children never present a murmur; but in neurotic and neuras- 
thenic children a disturbed or enfeebled condition of the central ner- 
vous system may manifest itself by debility which leads to cardiac- 
murmurs. It must be understood that whenever general debility is 
present, whatever its origin, this is shared by the heart and causes 
a tendency to murmurs. Therefore, loss of tonicity of the heart 
muscle prevents the prompt and complete closure of the valve seg- 
ments — in other words, the murmur is not valvular, but myocardial. 

How can we differentiate these from organic murmurs ? By consider- 
ing the murmur itself, and by noting the presence or absence of con- 
stitutional local disease. A functional cardiac murmur is always >y>- 
tolic in time, usually soft, blowing, and short, and involves almost 
exclusively the left heart — that is, the pulmonic, rarely the mitral 
area. The heart sounds may be altered, but not absent; they vary 
more in time than do organic murmurs, being present at one time and 
absent at another, and also vary with the posture, as when the child 
lies down or sits up, and after exercise. 

When cyanosis, dilatation of the right heart, and clubbing of the 
fingers and toes are marked, and associated with a loud rasping mur- 
mur, it is not difficult to recognize a congenital origin; but when the 
murmur is the only evidence it is sometimes hard to differentiate 
congenital from functional murmurs. However, for practical purposes, 
this is of little importance when other signs and symptoms of heart 
disease are lacking. Only long-continued observation will enable us 
definitely to determine the underlying lesion, and make an accurate 
diagnosis. Summarizing, we would say it is most important to realize 
that functional murmurs not only exist but are common in children, 
and that the mere presence of a murmur does not necessarily indicate 
disease of the heart. 

Reduplication of the second pulmonary sound may occur in healthy 
29 



450 DISEASES OF THE HEART 

little children as the result of crying or excitement, the closure of the 
pulmonary valve preceding that of the aorta. A faint venous hum in 
older children is not infrequently heard at both sides of the sternum, 
diminishing when the child assumes the horizontal position. A similar, 
but long and almost continuous, bruit is sometimes heard to the right 
of the sternum at about the third intercostal space, and is increased 
during the systole; it apparently originates in the superior vena cava, 
but varies considerably. This occurs chiefly in the anemic child; 
but when dealing with the tuberculous patient it may suggest the pos- 
sibility of compression by enlarged bronchial glands. 

In deciding whether organic heart disease is acquired or congenital, 
the following points are worthy of consideration: loud, rough, musical 
murmurs without increase in cardiac dulness, or, in the first and second 
years, such bruits with a weak apex beat and increased cardiac dulness, 
as well as bruits preponderating in the pulmonary area, all indicate 
congenital heart disease; very loud mumurs all over the heart, without 
a thrill, indicate a patent septum. A systolic murmur with a thrill, 
its maximum intensity over the upper part of the sternum, and no 
cardiac hypertrophy, indicates in all probability an open ductus 
arteriosus. Arteriosclerosis, chronic myocarditis, poisoning by tobacco 
or alcohol, or a fatty heart is only exceptionally found when studying 
diseases of the heart in children. 

CONGENITAL DISEASES OF THE HEART. 

The complicated normal process by which the simple tube of the 
primordial heart becomes transformed into a system of contractile 
spaces is a masterpiece of art that even Nature does not always succeed 
in carrying out to perfection. It can readily be understood that devia- 
tions of the simple parts from the normal in size, direction, or position, 
due to disease or other adverse factors which must be in operation 
early in fetal life, should leave some defect in the heart's otherwise 
perfect structure. Another element, fetal endocarditis, or an inflam- 
mation set up soon after birth, may in itself cause cardiac disease. 
However, not all congenital cardiac diseases can be attributed to either 
mechanical or embryonic causes. 

Most of these conditions are due, not to disease, but to faulty devel- 
opment. In 15 per cent, of the cases they form only one of several 
deformities, such as cleft-palate, undescended testicle, supernumerary 
or web-fingers, talipes, or microcephaly, and are evidently the expres- 
sion of a general tendency to maldevelopment or, as in Mongolian 
imbecility, exhaustion products. Depressing influences which impair 
the mother's perfect power of reproduction (syphilis, for example), 
or poisons which act upon the embryo, such as alcohol, tobacco, lead, 
or mercury, are undoubtedly important etiologic factors, and give 
evidence of their effect sometimes in two or three members of one 
family. Most cases, however, are due to faulty development, and only 
very few to so-called fetal endocarditis. 



CONGENITAL DISEASES OF THE HEART 



451 



In the order of their frequency lesions take place as follows: A 
defect in the ventricular septum; a defect in the auricular septum; 
pulmonary stenosis; patent ductus arteriosus; abnormal origin of the 
great vessels. In the great majority of these cases there are several 
lesions, consequently a correct diagnosis is difficult, and sometimes 
practically impossible. 

Clinical Symptoms. — The most striking symptom is cyanosis, which 
is present in many severe cases, but absent in about 60 per cent. It 
may manifest itself at birth or soon after, giving the skin and mucous 
membrane a dark leaden color, if intense, and when slight a bluish 




Fig. 32. — Infant's heart, showing congenital lesions. The right ventricle laid open, 
incision extending outward through the aorta, which communicates with both ventricles. 
The aorta is open and its valve leaflets are shown at AAA. Between D and E is the 
incision which extends outward through the pulmonary artery. B and C are leaflets of 
the tricuspid valve. D, the sinus that communicates with the pulmonary artery and con- 
stitutes the opening of the vessel in the right ventricle. E, the semilunar communica- 
tion between the two ventricles just below the aortic orifice. 



tint on coughing or crying; although healthy infants also may turn 
cyanotic during a prolonged crying spell. Some children show a slight 
bluish color only in the finger tips and toes. Marked cyanosis may 
not appear before puberty, and in other cases it becomes more obvious 
year by year. It has a certain value in prognosis, inasmuch as cases 
in which the cyanosis is severe usually do not live long, while in the 
less severe, or those in which it appears only in later life, the prognosis 
is more favorable. 

This cyanosis seems to be partly due to obstruction of the lungs, 
deficient oxygenation, and to polycythemia — that is, 6,000,000 to 



452 DISEASES OF THE HEART 

8,000,000 of erythrocytes, with an increased amount of hemoglobin. 
Cyanosis is usually accompanied by clubbed fingers and toes, probably 
owing to venous obstruction. The respiration in cyanotic cases is 
generally accelerated, sometimes difficult, and increases the tendency 
to acute bronchitis or bronchopneumonia, — the usual termination of 
congenital heart disease. 

Edema of the face and lower extremities, dropsy, and epistaxis are 
comparatively rare. The pulse is usually small, rapid, and easily 
compressible; sometimes it is irregular in rate and variable in strength. 
These children are often inclined to diarrhea, and especially to vomit- 
ing which recurs for months; they develop slowly, are undersized, 
and are living problems of nutritional difficulty. Irritable or apathetic, 
easily fatigued and short of breath, complaining, perhaps, of pain 
over the heart, these children find walking increasingly difficult and 
climbing impossible. They finally cease to walk, and take to their 
beds, there to end their short lives, dying from the disease itself or 
some complication, usually pulmonary. Some, however, have lived 
for 15 to 25 years, and even beyond this. 

Clinically, we distinguish three distinct groups of congenital diseases 
of the heart, as follows: 

I. Abnormal persistence of fetal conditions. 

(a) Patent ventricular septum. 

(b) Patent foramen ovale. 

(c) Patent ductus arteriosus. 
II. Deformities of valves. 

(a) Pulmonary stenosis or atresia. 
(6) Aortic stenosis. 
(c) Tricuspid stenosis. 
III. Abnormalities of vessels and of the cavities of the heart. 

(a) Abnormally large or small pulmonary artery. 

(b) Transposition of vessels. 

(c) Single ventricle with single or double auricle. (The latter 

is of no practical importance, because such children 

die within a few hours after birth.) 
I. Abnormal Persistence of Fetal Conditions, (a) Defect in the Ven- 
tricular Septum. — This is the most common congenital lesion of the 
heart; and, as it is always due to a defect in development, it is fre- 
quently associated either with pulmonary stenosis or other anomaly of 
development, such as hare-lip, etc. The opening is usually located in 
the upper membranous part of the septum, and is about one-fourth 
to one-half inch in diameter; but the septum may be almost wholly 
wanting, in which case there may be scarcely any bruit present. 

In the majority of cases, however, the defect manifests itself princi- 
pally by a loud, rough, systolic murmur which, although heard all 
over the heart, is of maximum intensity in the second or third inter- 
space close to the sternum, and is transmitted to the back, but not to 
the carotids. The pulmonary second sound is almost always accen- 
tuated, except in the cases where the opening is minute. 



CONGENITAL DISEASES OF THE HEART 453 

In the later stages of the disease a certain amount of hypertrophy 
and dilatation of the right ventricle becomes clearly distinguishable. 

There is usually no cyanosis, and the general health is so little affected 
that the lesion may be found accidentally rather than by intent, and 
the patient live to old age. 

Diagnosis in early infancy of a defect in the ventricular septum is 
often not difficult if a diffuse systolic murmur is detected, with its 
maximum intensity close to the left side of the sternum, with no change 
in cardiac dnlness, with an accentuated second pulmonic sound, and 
absence of cyanosis. In later childhood similar signs on percussion 
and auscultation may be found in diseases of the mitral valve; but the 
maximum intensity is at the apex, and the less rough and more local- 
ized character of the murmur, with, possibly, a history of rheumatic 
infection, will help in the differentiation. When the lesion is asso- 
ciated with open ductus arteriosus, pulmonary stenosis, or both, a 
positive diagnosis is often difficult, and the prognosis is poor. 

(b) Patent Foramen Ovale. — This is of very frequent occurrence, 
but is not always recognized during life because it may give rise to 
no symptoms whatever. 

(c) Persistent Ductus Arteriosus. — The ductus arteriosus should 
close during the first four weeks after birth by overgrowth of the cells 
in its inner wall. Under abnormal conditions, such as atelectasis or 
cardiac defects, these cells break down and the duct remains open. 
It seldom occurs alone, being usually associated with defects of the 
septum or the pulmonary valve. 

During early life a systolic murmur is heard, its maximum intensity 
being at the pulmonary area, and probably caused by the whirl pro- 
duced by the meeting of blood streams from the pulmonary artery and 
the aorta. The bruit is transmitted to the carotids. In later life a 
distinct thrill is felt over the base of the heart. The second pulmonary 
sound is accentuated ; the upper portion of the sternum may be bulging. 
Hypertrophy and dilatation of the right ventricle as well as dilatation 
of the pulmonary artery rapidly take place, and may be demonstrated 
by dulness in the second intercostal space. 

In uncomplicated cases the general health may be undisturbed for 
a long time. There is rarely dyspnea or cyanosis; on the contrary a 
deathly pallor is often seen. Subsequently there is a disposition to 
catarrh. The diagnosis can be definitely made only in cases uncompli- 
cated by other congenital cardiac defects. 

II. Deformities of Valves. Pulmonary Stenosis. — Of much greater 
clinical importance is pulmonary stenosis, which is one of the most 
common and serious congenital lesions due either to malformation 
or fetal endocarditis. The stenosis may be slight or grow to almost 
complete atresia, and may be situated at the pulmonary orifice in the 
conus arteriosus or in the pulmonary artery just beyond the valve. 
It is compatible with long life when association with other defects 
compensates for it; for instance, when there is a patent ductus arte- 
riosus which permits the blood to flow to the lungs from the aorta, and 



454 DISEASES OF THE HEART 

a patent ventricular septum which allows blood to flow to the left 
ventricle that cannot be forced through the stenotic pulmonary valve 
to the lungs. 

Cyanosis more constantly accompanies pulmonary stenosis than 
any other congenital heart lesion. It is usually marked at birth, and 
increases to a dark slate color on crying or any other exertion. Club- 
bing of the fingers and toes is especially marked. There is a decided 
tendency to lung affections, dyspnea, dizziness, vertigo and attacks 
of suffocation. 

A loud systolic murmur in the left second interspace and a lacking 
or weakened second pulmonary sound are characteristic. The murmur 
is not transmitted to the vessels of the neck except when due to a 
defective interventricular septum; the blood rushes directly to the left 
ventricle, and thence to the aorta. When associated with an open 
ductus arteriosus the second pulmonic sound may be accentuated, 
and the murmur together with a thrill be transmitted to the carotids. 
After a lapse of years dilatation and hypertrophy of the right ventricle 
become marked, and in many cases death occurs from pulmonary 
tuberculosis. 

t (b) Congenital Stenosis of the Aorta. — This condition may be found 
at the point of origin, at the entrance of the ductus Botalli, or through- 
out the entire aorta. If pronounced, life is sustained but a short 
time while the blood continues to circulate through the ductus arte- 
riosus. Stenosis of the isthmus, i. e., near the entrance of the ductus 
arteriosus, if not too extreme, can be successfully overcome by hyper- 
trophy of the left ventricle. A systolic murmur is heard over the upper 
part of the sternum and the second pulmonic sound is normal. If the 
patient lives, collateral circulation is established through the inter- 
costals and the internal mammary arteries, and the parts below the 
isthmus are better supplied. 

III. Abnormalities of Vessels and of the Cavities of the Heart. — (a) 
Is not a common malformation, (b) Transposition of vessels is not 
uncommon, and is always found to be associated with some other 
congenital heart defect. The aorta may arise from the right ven- 
tricle, or the pulmonary artery from the left ventricle. Occasionally 
a common trunk may serve as the origin of both the aorta and the 
pulmonary artery. Dextrocardia, or transposition of the heart, is 
very rare, (c) This form of congenital heart disease is of little 
clinical importance, as the condition is usually incompatible with life. 

PHYSICAL EXAMINATION IN DISEASES OF THE HEART. 

Physical examination of the heart in children calls for the greatest 
care, everything depending upon accurate observation, since we get 
little or no information from the child. Generally speaking, the situ- 
ation of the apex beat depends upon the development and shape of 
the chest, but it changes also with the position of the patient. As a 
rule, before the seventh year the impulse is found outside of the median 



PHYSICAL EXAMINATION IN DISEASES OF THE HEART 455 

line, later at about the nipple line. Moderate displacement to the left 
occurs with cardiac hypertrophy, especially of the left ventricle, while 
if to the right it suggests hypertrophy chiefly of the right ventricle. 
Extreme displacement points to an outside cause, such as pleurisy or 
empyema. 

As mentioned before, the pulse gives us no assistance except in acute 
pericarditis where we find continuous rapidity with progressive diminu- 
tion in volume, and in renal disease where arterial spasm finds its 
expression in a hard pulse with high blood-pressure. 

Inspection, also, is very unsatisfactory in children. The child must 
be stripped and examined in a good light. In infants the impulse is 
comparatively weak, while in the well-fed the chest walls are so well 
covered that the apex beat is invisible. Precordial prominence soon 
occurs in young children with rachitis, or after this disease; sometimes 
also in hypertrophy, and when there is a large pericardial effusion. 
Valvular disease or adherent pericardium produces a wide area of 
visible pulsation. 

Palpation. — In palpation the whole hand should be pressed gently 
but firmly over the precordial area while the child is sitting with its 
body bent slightly forward; the finger will then quickly find the point 
of greatest impulse. Thrills resulting from congenital or acquired 
heart disease are easily located, and the force of the systole gauged. 

Percussion. — Percussion is best performed in infants while recum- 
bent, and in older children in the upright posture. It should be done 
very lightly, bearing in mind the extreme thinness and elasticity of 
the chest wall. The area of relative cardiac dulness is proportionately 
larger in children than in adults, and is the greater the younger the 
child. Failure to allow for this might lead to an erroneous diagnosis 
of hypertrophy. As regards the relative and absolute cardiac dulness, 
we would say (avoiding too great refinement) that for most clinical 
purposes it is sufficient to remember the following points concerning 
their location: 

Relative Cardiac Dulness. 

At one year. At six years. At twelve years. 

Upper limit: Second costal Second intercostal space. Third cartilage. 

cartilage. 

Right margin: Right para- Slightly more to the left. About midway between the 
sternal line. parasternal and the right 

border of the sternum. 

Left border: Slightly beyond Slightly beyond the apex Slightly beyond the apex 
the apex beat. beat. beat. 

Absolute Cardiac Dulness. 

At one year. At six years. At twelve years. 

Upper limit: Lower border Upper border of fourth rib. Lower border of fourth rib. 

of third rib. 

Right margin: Left border of Left border of the sternum. Left border of the sternum. 

the sternum. 

Left border: Does not quite Does not quite reach the Does not quite reach the 

reach the mammary line. mammary line. mammary line. 



456 DISEASES OF THE HEART 

Method of Percussion. — The best results seem to be obtained by 
percussing on the left side from the anterior axillary line toward the 
heart in lines parallel with the 2d, 3d, 4th, and 5th interspaces, and on 
the right side from the right mammary line along the 4th interspace 
toward the sternum. For clinical purposes, it is quite sufficient to 
make out this most projecting part, which corresponds to the curve 
of the right auricle to the right of and behind the sternum. The 
younger the child, the more difficult it is to mark out the area of abso- 
lute cardiac dulness, and it is certainly more important to determine 
the apparent size of the heart than the area not covered by the lungs. 

Auscultation.— All sounds are comparatively louder and are diffused 
over a greater area in children than in adults. In infants the muscular 
quality of the first sound is rather of the type of the fetal tic tac. In 
children the second aortic sound is normally weaker than the second 
pulmonic. Reduplication of the sounds is not infrequently heard in 
children who are excited, and may mean nothing more than that the 
valves of the two sides do not close at exactly the same time. A dimi- 
nution or absence of the second pulmonic sound is invariably found in 
pulmonary stenosis; an increased apex beat with a rather diffuse, 
dull, first sound, strongly points to cardiac hypertrophy; while a weak 
and distant apex beat is highly suggestive of either dilatation of the 
heart or pericardial effusion. The latter, which is comparatively rare, 
is confirmed by a friction rub and pain on pressure over the precordial 
area. 

THE GENERAL SYMPTOMS OF HEART DISEASE. 

The general symptoms of heart disease are no indication of the sever- 
ity of the affection, and even in children with serious lesions they may 
be slight or often totally absent. As already mentioned, cyanosis, 
although a frequent accompaniment of congenital heart disease, may 
be absent, as evidenced by the pallor usually seen in those who suffer 
from aortic disease. In mitral disease congestion is the rule; while in 
malignant endocarditis the grayish color and pinched expression often 
tell the story. Attacks of fainting, sometimes difficult to differentiate 
from petit mat and the functional disturbances of puberty, are not 
rare. 

Muscular weakness, anemia, malnutrition, and shortness of breath 
on exertion, all call for an examination of the heart. Marked edema, 
digestive disturbances, and angina are seldom met with in childhood; 
but restlessness, vomiting, subnormal temperature, and pallor are 
grave symptoms in children suffering from cardiac disease. 

Although the recuperative power of a child's heart is considerable, 
yet in various diseases there is an increased tendency to heart compli- 
cations, and the child is more liable to an aggravation of an already 
existing cardiac affection than is the adult; valvular lesions are apt to 
be multiple, pericardial adhesions and cardiac hypertrophy frequently 
occur, and when circulatory disturbance is of severe type and begins 
early in life, growth and development are considerably retarded. 



ACUTE ENDOCARDITIS 457 



ACUTE ENDOCARDITIS. 

The usual clinical classification of endocarditis, myocarditis, and 
pericarditis is based on the most striking symptoms of each of these 
diseases; but it is well to emphasize the fact that in any of these con- 
ditions the child's entire heart is more or less involved. Simple endo- 
carditis may, in rare cases, be intra-uterine in origin, and is then usually 
localized in the right heart. Postnatal endocarditis, in which 
group the majority of cases belong, seldom occurs under three or four 
years of age, because at least 75 per cent, of these cases are due to 
acute rheumatism and chorea, which are both rare before the fifth 
year. It appears most frequently between the sixth and twelfth years, 
being less common in children of the well-to-do, because to some extent 
preventable. 

While the chief cause in all of these cases is rheumatism or chorea, 
yet it not infrequently follows the infectious fevers, especially scarlet 
fever, influenza, and pneumonia, also pleurisy, bronchitis, and pyemic 
conditions. A cold, damp season, overexertion in anemic or rapidly 
growing children, shock, fright, bad habits, severe digestive disturb- 
ances, all favor the infection, especially when rapid growth and devel- 
opment at puberty severely tax an already weakened heart. 

Summarizing, we would say that endocarditis almost invariably 
appears as a secondary infection. Even when apparently primary, 
thorough investigation will prove that either rheumatism (of which a 
cardiac affection may be the first manifestation) or, in rare cases, tuber- 
culosis is the real cause. The Streptococcus viridens is the principal 
offender in the smouldering type of endocarditis (malignant); but 
staphylococci, pneumococci, gonocci, the Bacillus typhosus, and the 
Bacillus coli communis are also not infrequently found. 

Pathology. — The pathological lesions are mostly confined to the left 
side of the heart, involving the mitral, and much less frequently the 
aortic valves. The hyperemia, swelling, inflammation of the cells, 
and wart-like excrescences on the free margins of the thickened 
valves do not essentially differ from those in the adult. There is, 
however, the difference that, when the lesions are slight, apparently 
complete healing takes place, and the ulcerative form is extremely 
rare in children. 

Symptoms. — These are often remarkably latent, the insidious onset 
being expecially noteworthy. There may be vague pains, the so-called 
growing pains, or repeated attacks of angina and sore throat; but in 
many cases nothing draws attention to the diseased heart until breath- 
lessness disproportionate to the exertion becomes noticeable. 

Unless the first symptoms are masked by an underlying disease, 
weakness, pallor, failing appetite, and slight irregular fever ensue, 
the latter disappearing when the child rests in bed, and reappearing 
when he gets up. After an interval, the pulse gradually grows rapid, 
irregular, and low in tension; subsequently a characteristic blowing 
murmur makes its appearance, at first gradually increasing, later, 



458 DISEASES OF THE HEART 

possibly, diminishing, being systolic in time and frequently accom- 
panied by a thrill. 

Sometimes a child is brought to the physician for symptoms directly 
traceable to the heart, i. e., palpitation, precordial pain, and shortness 
of breath; but whenever a stiff neck, fleeting pains in the joints, and 
so-called growing pains are complained of, it is advisable to examine 
the heart. 

In the earliest stages there may be no bruit at all, only very slight 
increase in the area of cardiac dulness, and sometimes only a rapid and 
irregular pulse. A deep dulness should be carefully noted, because 
dilatation occurs easily and early; in fact, it may be the first or only 
sign of an affection of the heart. 

Careful estimation of the size of the heart is often more enlightening 
than the auscultation of a murmur, but it requires considerable train- 
ing. In the early stages, more or less dilatation of the left side is often 
caused by toxic or inflammatory changes in the cardiac muscle itself; 
but in advanced cases special attention should be paid to the right 
border, because dilatation of the right heart, unless quickly relieved 
by bleeding, leads to lividity, ascites, enlarged liver, and extreme 
dyspnea. 

Hypertrophy of the heart following increased work against higher 
pressure in the arterial system (especially in nephritis) causes bulging of 
the precordia more readily in children, because the chest walls are so 
pliable. In auscultating, certain differences between the signs in chil- 
dren and in adults must be taken into consideration. Aortic bruits 
are very rare in children, but do occur after mitral disease, the murmur 
being systolic in time; later, when the valves shrink, a diastolic bruit 
may be added. These murmurs are usually audible in the second or 
third interspace close to the sternum or over the middle of the sternum. 

The vast majority of cases are due to lesions of the mitral valve, 
manifesting themselves by a weakened first sound at the apex, which 
becomes impure, and later may be replaced by a bruit which is blowing 
and soft, and may be transmitted, The second sound is at first clear 
and well defined, but soon becomes less distinct and is reduplicated. 
After a time a short puff develops; this is less loud and shorter than 
the systolic bruit; thus we have the well-known double murmur at 
the apex. 

On account of its splendid reserve power the left heart easily over- 
comes the obstruction, so that for a long time there may be no accen- 
tuation of the second pulmonic sound, and no enlargement is demon- 
strable by percussion or the a;-rays. Hypertrophy and dilatation occur 
much later in children than in the adult. It must be borne in mind 
that the clinical picture in infants differs considerably, and a diagnosis 
can seldom be made, chiefly because the infant or child has always 
had a congenital murmur, due to a congenital lesion, and the endo- 
cardial murmur having developed subsequently and in addition to the 
congenital one it was, therefore, not noticeable. 

The course of the disease shows great variations, and a fatal issue 



ACUTE ENDOCARDITIS 459 

usually occurs in infants when myocarditis and pericarditis compli- 
cate matters, or malignant endocarditis supervenes. Acute endocar- 
ditis ends in chronic valvular disease except in the few cases in which, 
within a few weeks, or months, the murmur gradually disappears and 
the slightly affected valves to all appearances return to the normal. 
Malignant endocarditis, which is very rare in children, is usually secon- 
dary to simple endocarditis, or may follow erysipelas, scarlet fever, 
septicemia, and infection of the oral cavity or of the bladder. 

Diagnosis. — As a rule the diagnosis cannot be made until the emboli 
lodging in the kidney, brain, intestine, or lungs lead to infarcts or mul- 
tiple abscesses; this is chiefly because cardiac murmurs and dilatation 
often jio not appear until shortly before death, which usually occurs 
within a few weeks. Clinically, it presents symptoms of typhoid 
fever or pyemia; i. e., fever, prostration, sometimes delirium, an enlarged 
spleen, and meningeal symptoms. 

The diagnosis sometimes presents considerable difficulty. First, 
accidental murmurs must be excluded. Only when a daily careful 
examination reveals a bruit of gradual onset, which is persistent and 
more or less uniform in character, may we feel sure of existing endocar- 
ditis. Sometimes the symptoms themselves may be so marked as to 
suggest the disease; but it is only by carefully eliciting the physical 
signs that the suspicion may be verified and the diagnosis confirmed. 
On inspection a rapid diffuse apex beat, with sometimes an undulating 
motion over the precordia, may indicate cardiac overactivity. Pal- 
pation confirms the strong, irregular heart action. On percussion, even 
in the early stages, increased cardiac dulness, especially on the left 
side, is not infrequently found. 

But it is chiefly by auscultation that we are enabled to decide as 
to the character of the murmur, this depending on the valve involved 
and the nature of the valvular lesion. Examination of the heart in 
children is greatly simplified by the fact that in them acute endocarditis 
is almost invariably limited to the left side. The murmur may be 
single or multiple, systolic, diastolic, or presystolic in time, and soft, 
blowing, harsh, grating, or rough in character. As mentioned before, 
in the majority of cases the mitral valves are involved. 

With mitral regurgitation we find a soft, blowing, systolic murmur 
the greatest intensity of which is toward the apex; it is usually trans- 
mitted outward to the axilla, and is often distinctly audible posteriorly 
between the scapula and the spine. 

Mital stenosis occasions a presystolic bruit which is not transmitted, 
but is usually accompanied by a thrill, and is loudest between the mitral 
area and the apex. 

More often than with a single murmur we have to deal with a double, 
sharp, presystolic mitral murmur, followed immediately by a systolic 
murmur which almost drowns the first sound. The systolic murmur 
of aortic stenosis is loudest over the aortic area, is transmitted to the 
carotids, and, especially in younger children, is audible over the middle 
of the sternum. Aortic regurgitation is characterized by a diastolic 



460 DISEASES OF THE HEART 

murmur, heard principally' between the second and third intercostal 
spaces. 

Differential Diagnosis. — In children pericardial murmurs are to be 
distinguished, as in the adult, chiefly by the triangular area of cardiac 
dulness, the base of- the triangle corresponding with the apex beat, 
the apex pointing toward the great vessels, and gradually so increasing 
that the cardiohepatic angle and Traube's area below the heart tend 
to disappear. Difficulty in differentiating functional murmurs is really 
experienced only when we are dealing with a soft, blowing, mitral 
lesion. The accidental murmur in these cases is inconstant, changes 
more or less, may even disappear on change of position, and, as a rule, 
is not distinctly transmitted. Under proper care it usually passes 
away after a short time. There should be no accompanying cardiac 
hypertrophy. 

Prognosis. — The prognosis of endocarditis is always grave. The dis- 
ease is usually fatal in infants, the danger to life in older children being 
rather remote. Some may remain in a more or less invalid condition, 
but the case does not necessarily go from bad to worse; in fact, the 
greater number recover more or less completely if treated efficiently 
from the beginning. 

But in some cases, even with the best of care, the valves are impaired 
for life, and as long as evidence of rheumatism persists there is danger 
of further cardiac mischief. Considering that the tendency to rheuma- 
tism and chorea is greatest between the fifth and twelfth years, the 
earlier the first attack of heart disease occurs, the greater is the prob- 
ability that the condition will be aggravated by subsequent attacks; 
consequently, after puberty the chances for comparative comfort 
steadily improve. 

Pericarditis is the one complication most to be feared; many cases 
end fatally within a month or two, and all lead to adhesions which grad- 
ually cause hypertrophy and dilatation, and end in ruptured compen- 
sation. On the other hand, it cannot be. too strongly emphasized that 
loud murmurs, unquestionably of rheumatic origin, may disappear 
completely, and thus they warrant a hopeful outlook, especially when 
of recent origin; even in advanced cases we may hope for considerable 
improvement. Ulcerative endocarditis, fortunately extremely rare 
in children, probably in all cases ends fatally within a few weeks. 

Treatment. — It is the mild case that presents the most serious prob- 
lem, because, owing to the lack of objective symptoms, the parents 
are not easily con viced of the gravity of the disease. , The remedy 
par excellence is rest, and rest in bed. Whether we are dealing with a 
mild or a severe case, our chief aim is to tax the heart as little as pos- 
sible. No strain or stress of any kind should be allowed; even the use 
of the arms and legs had better be restricted, especially in the first 
stage, which is the time when most damage is done. This should be 
kept up for weeks until the heart becomes more regular, less excitable, 
and can endure slight exercise tests, and the treatment must be insisted 
upon in spite of the protests of both parents and children. 



ENDOCARDITIS OR ACQUIRED VALVULAR DISEASE 401 

In this connection it may not be amiss to emphasize the importance 
of sleep as the best means of securing rest. It may even be necessary 
to resort to drugs, as codein or bromide, for this purpose, especially 
in the more advanced stages of the disease. Ordinarily a comfortable 
bed, a quiet, darkened room, and a tactful nurse are sufficient; in order 
to avoid too frequent disturbance of the child, it is advisable to give 
medicine and food at the same time. 

An ice-bag, half-filled with shaved ice and applied over the pre- 
cordium usually quiets and slows the heart. Children, however, do 
not always take kindly to this measure, and if it makes them irritable 
or restless it had better be removed for a short time, and then applied 
again. Of course, it cannot be used on the infant. 

Diet. — No tea or coffee should be given. In the beginning the child's 
food should be mainly liquid, varied by the addition of gruels, broths, 
and custards — not a strictly milk diet, of which the child soon becomes 
surfeited, and which it refuses, consequently is apt to suffer from under- 
nourishment. 

With progressive improvement, eggs, bread and butter, and stewed 
fruits may be added; later poultry, fish, and simple puddings provided 
they do not distend the stomach. Saline laxatives may be necessary 
to insure a daily bowel movement. 

Drvgs. — Salicylates combined with double their amount of alkali, 
or aspirin, which is less irritable to the stomach, should be given when- 
ever there is evidence of rheumatism or the least suspicion of endocar- 
ditis, unless the latter can be traced to diphtheria or an infectious fever. 
This medication should be kept up until the fever and rapid cardiac 
action abate, and even then small doses may be given at short intervals. 

It is advisable to continue this medication for at least a month, 
and afterward to repeat it for one week in every month to ward off 
any possibility of a recurrence, especially when there are signs of ton- 
sillitis or other manifestations of a rheumatic tendency. Ordinarily dig- 
italis can be dispensed with; when, in severe cases, stimulation seems 
imperative, camphor and caffeine are preferable, while for excitement 
and restlessness five to ten grain doses of sodium bromide and | 
grain of codeine, p.r. n., are permissible and even advisable. 

If, during convalescence, the pulse is well below 100, the child may 
gradually be propped up in bed for an hour a day and, if the heart can 
stand it, very cautiously gotten up in a reclining chair. So, little by 
little, and chiefly guided by the heart action, the child may increase 
its exercise every day, and gradually resume its normal life. Diseased 
tonsils and adenoids should be removed. 



CHRONIC ENDOCARDITIS OR ACQUIRED VALVULAR DISEASE. 

Valvular defects usually follow an endocardial infection which, in 
the majority of cases, is rheumatic in origin; therefore they rarely 
originate before the third year, but almost always appear after the 
fifth, There is, of course, no definite time limit for the acute condition, 



462 DISEASES OF THE HEART 

which, indeed, may gradually run into the chronic. It is true that the 
preceding acute endocarditis is often either not suspected or not 
diagnosed; nevertheless, the most important etiological factor is usually 
a rheumatic affection; arteriosclerosis and poisons, such as alcohol or 
syphilis, being rarely the cause of valvular disease before puberty. 

Symptoms. — These may make their appearance very insidiously, 
and depend in some degree upon the character and the site of the lesion. 
They may be latent for years, the child looking well, appearing vigorous 
and showing good powers of endurance up to puberty, the cardiac de- 
fect often being discovered accidentally during a routine examination 
of the heart. Some patients are rather irritable, easily tired, pale 
at times, and complain of headache after mental or physical exertion. 
Other subjective signs are slightly disturbed compensation, or nose- 
bleed which may be repeated and violent and accompanied or followed 
by headache, ringing of the ears, dizziness which is increased on stoop- 
ing, or shortness of breath on climbing or running upstairs, and 
persisting for some time after exertion. 

Children very rarely complain of cardiac palpitation; but a stubborn 
catarrh of the respiratory passages, an irritating little cough, coryza, 
and swollen turbinals, diminished appetite, vague pains in the back 
and nape of the neck, may all indicate an undiscovered cardiac 
affection. 

With the advent of disturbed compensation these symptoms become 
exaggerated and, in addition, are associated with a consequent mechani- 
cal impairment of the circulation as shown by cyanosis of the lips, 
the fingers, and the toes, enlarged veins of the neck, scalp, and thorax, 
enlarged and, possibly, tender liver, edema of the limbs and of the 
peritoneal, pleural, and pericardial cavities. Dyspeptic symptoms 
are conspicuous in all of these cases. 

Physical Signs. — In valvular disease of the heart in children the 
physical signs are for the most part identical with those in the adult, 
although children do not usually complain of palpitation, the cardiac 
impulse being visibly and palpably strong. When the lesions are severe 
the bulging of the precordia is the more marked the younger the child. 
Often no such bulging is found; for years there may be no perceptible 
difference on percussion; the area of dulness may be only slightly 
extended to the left, as revealed by x-ray examination. 

Murmurs. — Organic murmurs are usually distinct, often loud and 
rough, especially over the apex, and they are heard not only over their 
respective areas, but very often in older children, always in younger 
ones, also in the back between the shoulder blades and at the angle 
of the scapula. Only when the compensation is ruptured is the area 
of cardiac dulness greatly extended on the right side, this suggesting 
pericardial effusion for which, in fact, it is often mistaken. 

The Pulse. — If the cardiac muscle is involved, we may occasionally 
have arrhythmia. The special symptoms of disease of the different 
valves are, generally speaking, similar to those in the adult; but it 
must be emphasized that the most common clinical variety is mitral 



ENDOCARDITIS OR ACQUIRED VALVULAR DISEASE 463 

disease, which before puberty occurs about twenty times more fre- 
quently than do aortic valvular defects. Mitral insufficiency often 
appears alone, and represents the common form in early life. The 
murmur is more or less synchronous with the first sound, is best heard 
over the apex, and is transmitted to the left. The murmur is more or 
less diffuse, accompanied by an accentuation of the second pulmonic 
sound, and the signs of hypertrophy. 

Although the two latter points are important in differentiating 
organic from merely functional murmurs, it must be stated that they 
may not appear for quite a little time. Mitral stenosis usually com- 
plicates mitral insufficiency, but may not be detected until years 
after the appearance of the first lesion, while as an isolated or primary 
lesion it is hardly ever found before puberty. The bruit may be almost 
inaudible or may become noticeable only after exertion; as a rule it is 
rough, terminates sharply with the first sound (presystolic), is loudest 
at the apex, and strictly localized. 

Aortic disease is rarely observed before the tenth or twelfth year, 
insufficiency and stenosis appearing at about the same time. It is 
usually of serious import, and may cause sudden death. 

Stenosis is characterized by a systolic murmur, heard chiefly at the 
right border of the sternum and second interspace, and transmitted 
upward into the carotids. The second aortic sound is weak. With 
aortic stenosis there is necessarily present hypertrophy of the heart, 
although this is not as marked as in aortic insufficiency. If there is no 
hypertrophy the murmur is probably an accidental (hemic) one, 
therefore it would necessitate a revision of the diagnosis. Aortic 
insufficiency causes a prolonged diastolic murmur, coincident with or 
replacing the second sound. It is loudest at the left side, and is trans- 
mitted along the sternum toward the apex; associated with it is most 
marked cardiac hypertrophy which, of course, is especially noticeable 
when beginning failure of compensation causes dilatation of the left 
ventricle. There is also intense throbbing of the carotids. 

Tricuspid insufficiency is usually caused by dilatation of the right 
ventricle after a serious mitral lesion. It gives rise to a systolic murmur, 
the greatest intensity of which is over the lower part of the sternum. 
The jugular veins standout prominently, and mayshow systolic pulsation. 

As regards the future course of cardiac disease, there is no doubt 
that children may recover from mitral insufficiency, even though we 
have been careful to classify as such only those cases in which the bruit 
appears gradually after an acute rheumatic infection, and persists 
for months, or even for years. In the majority of cases, however, the 
disease remains more or less latent until puberty. There are cases in 
which serious manifestations appear after years of apparent latency, 
this probably being due to the fact that the cardiac muscle gradually 
becomes weaker and can no longer continue to compensate, i. e. } 
because of the necessarily increased amount of work, or because a 
fresh endocarditis is superimposed upon the old lesion. 

In the rare cases where death occurs in a comparatively short time 



464 DISEASES OF THE HEART 

(within a few months or years) we, no doubt, are dealing with more than 
a valvular defect; in all probability with pericarditis or myocarditis. 
In a general way, we may say that in children a purely valvular defect 
can be far better compensated, and for a longer time than in the adult. 
On the other hand, when failure of compensation appears the end is 
close at hand. 

Diagnosis. — In making a diagnosis of organic heart disease in 
children one cannot be too cautious. The same underlying principles 
as in the adult must be our guide. But there are added difficulties 
to be overcome in eliminating the different varieties of accidental 
murmurs, and it is sometimes almost impossible correctly to diagnose 
mitral insufficiency in children between five and fifteen years of age. 
On the one hand, in organic mitral insufficiency, enlargement of the 
left ventricle and accentuation of the second pulmonic sound may be 
absent for a long time; yet when the systolic murmur is not permanent, 
is loudest in the mitral area, is equally audible whether the patient is 
lying down or sitting up, and is associated with a heaving apex beat 
due to hypertrophy of the left ventricle, it cannot be clearly distin- 
guished from that due to mitral regurgitation. 

Furthermore, it must be differentiated in those cases of defective 
intraventricular septum when only the upper membranous part of 
the septum, is patent. In these cases there is a loud systolic murmur, 
audible over the whole heart (which may or may not be hypertrophied) , 
the murmur being most intense in the third left interspace, is trans- 
mitted to the back but not to the carotids, and may or may not be 
accompanied by an accentuated second pulmonic sound. Finally, 
it is well not to overlook the fact that in anemic school children absolute 
cardiac dulness is not infrequently increased on account of the insuffi- 
cient expansion of the margin of the lungs overlying the heart. If, 
in such a case, a hemic murmur is audible, the affection can easily 
be mistaken for organic disease. 

Treatment.— Prophylaxis practically resolves itself into the most 
careful treatment of any manifestation of rheumatism, including sore 
throat or chorea, also the observance of cardiac hygiene, with rest, 
and the use of the salicylates. Considering the fact that these rheu- 
matic affections have a tendency to recur, a weekly course of salicylates 
and alkalies once a month, or once in two months, seems a wise pre- 
caution. Whether we adopt passive treatment — that is, restriction 
of the ordinary routine of life — or active measures by drugs, etc., 
nothing should be done until the diagnosis is definitely settled. 

As long as compensation is maintained satisfactorily, no special 
treatment is necessary. The child need not be frightened, but the 
parents should be told of the condition so that they may guard against 
any excessive physical exercise, cycling, football, baseball, rowing, 
etc.; alcohol, tea, and coffee should be prohibited. While the whole 
life should thus be regulated, and the child carefully watched, there is 
no reason why it should be condemned to a life of invalidism; and the 
less interference the better for the patient. 



ACUTE PERICARDITIS 465 

Careful regulation of the exercise taken by the child is necessary 
from time to time, the physician being guided by the symptoms and 
physical signs of cardiac disease. This will enable him to decide upon 
the proper management of the individual case. All possibility of 
reinfection must, as far as possible, be prevented by avoiding exposure 
to cold and wet, and by having diseased tonsils, the teeth, the kidneys, 
or any general disturbances of the alimentary tract, promptly treated. 

Country life, especially in a warm and dry climate, is very beneficial, 
and a gradual hardening of the body against changes of temperature 
is to be recommended. Woolen undergarments should be worn, 
especially in the cold season. As soon as cardiac failure appears, rest 
becomes imperative, and such other measures or treatment should 
be applied as will improve the functional power of the left ventricle. 
All nervous strain should be removed, and rest for the heart and 
refreshing sleep secured by the judicious use of the bromides, morphine, 
or codein, and a carefully regulated diet; for the first eight days a 
somewhat restricted milk diet is probably the best. If these measures 
do not avail, it is then time, just as in the adult, to use digitalis, or 
any of the other heart stimulants, such as camphor, caffeine, adrenaline, 
or morphine. 

ACUTE PERICARDITIS. 

There is a mild form of pericarditis marked by a slight deposition 
of fibrin or a slightly increased amount of pericardial fluid. This may 
occur in the course of infectious diseases, and, as a rule, is not diagnosed 
unless it goes on to suppuration, as sometimes happens in scarlet fever 
and measles. But the more severe form of pericarditis is of real 
clinical importance. It occurs in general sepsis of the newborn and 
in young infants, and is usually purulent in character. Between the 
second and the seventh years the infection spreads from an adjacent 
focus in the lungs and pleurae, and is then usually caused by the 
pneumococcus. After this age most pericardial effusions are due 
either to tuberculosis or to repeated rheumatic infections. In these 
cases the functional capacity of the heart is threatened by adhesions 
which are liable to form when the effusion becomes absorbed. 

Summarizing, we would say that rheumatic infection is by far the 
commonest cause of pericarditis in children; but we must not lose 
sight of the fact that this pericarditis is always associated with endo- 
carditis and more or less involvement of the cardiac muscle. ^Yhile 
often obscured by the primary disease, that is, by sepsis, pleurisy, 
or pneumonia, the clinical picture of rheumatic endocarditis is clear- 
cut except when another underlying etiological factor (such as endo- 
carditis or arthritis, and in older children chorea) produces additional 
symptoms. 

Symptoms. — Acute pericarditis often begins with vomiting, fever, 

headache, loss of appetite, and restlessness, soon followed by pallor 

of the face, and later by lividity of the mucous membrane. The patient 

is short of breath, and a frequent, dry, irritating, little cough often 

30 



466 DISEASES OF THE HEART 

interferes with sleep. Pain over the precordium, or a sense of oppres- 
sion, is not always complained of, even when well-marked friction 
sounds are heard. 

The pulse usually becomes more rapid and weak. Upon examina- 
tion we may hear slight friction sounds which in the beginning may 
resemble a soft, blowing, endocardial bruit; but these sounds are 
variable, usually localized at the base, and sometimes increased by 
pressure with the stethoscope. The well-known triangular area of 
increased cardiac dulness with its apex toward the aortic area bears 
witness to the progressive accumulation of pericardial fluid. Traube's 
space is obliterated, and the cardiohepatic angle as well, because the 
exudate collects somewhat more to the right and left of the apex. 

The impulse often persists in palpable form for a long time, and the 
heart sounds become more and more distant. The greater the amount 
of exudate the greater the tax on the heart, which is manifested by a 
pulse rate of 140 to. 180, or even 190. Cyanosis, the fulness of the large 
cervical veins, marked swelling of the liver, and general edema are 
all due to congestion. 

When no absorption takes place, the feeling of oppression and the 
dyspnea continue to increase, and lead to cardiac weakness which ends 
fatally within a short time. Even absorption of the fluid does not 
necessarily indicate a cure, because the resulting adhesions of the 
pericardium considerably embarrass the heart, and quickly lead to 
hypertrophy. Death may be postponed for only a few years, especially 
when, as is often the case, there is a complicating endocarditis. 

Diagnosis. — As in the adult, the diagnosis rests upon the gradual 
increase of the triangular area of dulness, which obliterates the cardio- 
hepatic angle and Traube's semilunar space. The fact that the area 
of absolute cardiac dulness increases or extends more rapidly than that 
of relative dulness is a decided help. While a large effusion can hardly 
be overlooked unless there be an accompanying left-sided pleural 
effusion, it is often difficult definitely to diagnose a small effusion, 
especially in children; often the arrays alone can decide this question. 
The x-ray picture enables one also to differentiate these cases from 
cardiac dilatation. When it is a question in a given case whether the 
exudate is serous or purulent in character, a distinct increase in leuko- 
cytes favors the latter. 

Prognosis and Course. — These vary according to the individual 
conditions. Purulent cases, unless saved by surgical intervention, 
are likely to end fatally, while the non-purulent, which are chiefly 
of rheumatic origin, offer a good prognosis as to life, but not as to 
complete recovery; since, even though the fluid be absorbed, adhesions 
between the two layers and complete obliteration of the pericardial 
sac occur much more often in children than in adults, and, by crippling 
the heart permanently, mark the beginning of a life of invalidism 
which may be more or less prolonged. 

In mild cases, the outcome depends largely upon the management. 
As regards the duration of the acute symptoms, one week is the 



ADHERENT PERICARDITIS 467 

minimum in mild cases, while in severe ones they may last much 
longer; the average time being about three weeks. Recovery at 
best is slow, and only partial. 

Treatment. — The prophylactic measures discussed under endocarditis 
are applicable here also, especially precautions against recurrent attacks 
of rheumatic fever, the removal of diseased tonsils, etc. The first 
principle in the management of the patient during an attack is absolute 
rest in bed. The child should be allowed to do nothing that others 
can do for him, and should not get up until he can do so without any 
symptoms of heart strain. 

In cases of rheumatic origin, sodium salicylate should be adminis- 
tered, combined with a double quantity of bicarbonate of soda — 
5 grains of the salicylate and 10 grains of the soda every three hours 
to a child of five years. For delicate children and those who can- 
not tolerate the salicylates, aspirin is preferable, in doses of 8 to 10 
grains, three times a day, for a child ten years of age. 

The early and intermittent use of an ice-bag seems to quiet the heart 
action and reduce the fever. It should be continued only until the 
acute symptoms begin to subside; later, warmth seems preferable. 
In my experience counterirritants and blisters are of little use, therefore 
not recommended. 

The diet should be simple, nutritious, light, and somewhat restricted 
during the acute stage, consisting principally of cereals, milk, eggs, 
custards, and toast. 

Extreme rapidity of the pulse may be counteracted by the judicious 
use of tincture of strophanthus, which is superior to digitalis inasmuch 
as it does not so easily derange the stomach. When the patient i> 
restless or distressed, morphia, in y ( y to 5V of a grain doses, relieves 
pain and, at the same time, acts as a cardiac sedative. In the very 
young, sodium bromide should first be tried ; if it has no effect, pare- 
goric should be given in doses of 10 to 20 drops at three hour intervals, 
p. r. n., and in children above two years of age J to T V of a grain of 
codein (not more than three doses in the twenty-four hours) . 

Excessive exudate may call for surgical intervention. This, in fact, 
offers the only chance in an otherwise hopeless case of purulent effusion. 
When we are dealing with a serous effusion, a mere puncture of the 
pericardial sac may be sufficient. This puncture is usually made by 
means of a small aspirating trocar, either in the fifth right interspace, 
one and one-half inches to the right of the right sternal border, or in 
the fourth or fifth left interspace, at the same distance from the left 
sternal border, thus avoiding the internal mammary artery. After 
the trocar is introduced, the fluid is allowed to drain out slowly. 

ADHERENT PERICARDITIS. 

Adherent pericarditis is not unusual after the eighth year, and may 
follow a single or repeated attacks of pericarditis (usually rheumatic 
in origin), although the preceding disease may not have been recog- 



468 DISEASES OF THE HEART 

nized. The adhesions left after absorption of the exudate greatly 
hamper the heart, and thus give rise to hypertrophy and to dilatation 
of both ventricles. 

Morbid Anatomy. — The pericardium may be greatly thickened, 
or both of its layers, the parietal and visceral, may become adherent, 
thus partially or completely obliterating the pericardial sac. Some- 
times even external adhesions form and bind the heart to the chest 
wall, the pleurse, the mediastinal structures, or the diaphragm. When 
tuberculosis is the etiological factor, caseous deposits and tubercles are 
found. Other changes are usually also present, especially a low-grade 
myocarditis which causes increasing dilatation and weakening of the 
cardiac muscles. 

Symptoms. — These are often latent, and the condition may remain 
unrecognized in those cases where murmurs of valvular lesions or the 
symptoms of an underlying constitutional disease obscure the clinical 
picture. As a rule the symptoms are those of gradually increasing 
insufficiency, especially a rapid, weak, irregular pulse, easily affected 
by exertion, which also causes dyspnea and cardiac distress, finally 
leading to gradual failure or to sudden death. The apex beat is diffuse, 
often feeble, or even absent. 

The characteristic sign of adhesions between the pericardium and 
the chest wall is a systolic retraction of the latter at or near the apex 
of the heart. This must, however, be carefully differentiated from the 
systolic sinking of the intercostal spaces with marked apex beat which 
is found in cardiac hypertrophy. 

Almost equally characteristic is a diastolic rebound of the inter- 
costal spaces over the greater parts of the pericardium, associated 
with diastolic collapse of the jugular vein, and immobility of the heart-*- 
the position of the apex and the cardiac dulness in general not changing 
with the position of the child. 

All other symptoms, such as dyspnea, precordial distress, cyanosis, 
small pulse, and signs of hypertrophy and dilatation, may also be due 
to endocarditis or myocarditis, and can be regarded as suspicious of 
obliterative pericarditis only when there is a history of a preceding 
attack of pericarditis, from which the patient has not recovered. 

Percussion proves that the cardiac dulness is increased in all 
directions. The children are sickly; they do fairly well as long as 
they stay in bed, although the small, rapid pulse, and difficult respi- 
ration on the least exertion, show their true condition. As soon as 
they get up, however, they are easily fatigued, become cyanotic and 
dyspneic, and willingly take to bed. Sometimes the child may show 
considerable improvement for a while, then the heart again breaks 
down, with accompanying fever, bronchitis, pleurisy, and subsequently 
edema. The liver and spleen enlarge, ascites develops, and sooner or 
later death ensues. 

Diagnosis. — The diagnosis is often merely a surmise when neither 
the friction sound nor the exudate of preceding acute pericarditis 
has been observed. It may, however, be correctly made when 



; 



MYOCARDITIS 469 

symptoms of myocardial insufficiency follow an acute attack of per- 
icarditis. Although .r-ray examination may be a valuable aid, diagnosis 
is often very difficult, especially in the absence of the characteristic 
sign of systolic chest retraction. Adherent pericarditis in its later 
stages, characterized by lost liver and ascites, can be differentiated 
from cirrhosis of the liver by the concomitant cyanosis, the small, 
rapid pulse, and extreme dyspnea. 

Prognosis. — This is unfavorable in all but the mildest cases, death 
invariably occurring after a few months or years. For this reason all 
treatment is unsatisfactory, and must be symptomatic, as in myo- 
cardial insufficiency. On account of the accompanying myocardial 
degeneration, even digitalis is unavailing. Embarrassing pleural or 
abdominal effusions should be removed by puncture. Placing the 
child on a nourishing diet, giving it good general care, and, perhaps, 
injections of fibrolysin, are all that can be done to insure the patient's 
temporary comfort. Operation with a view to freeing the external 
adhesions of the heart can hardly be considered in childhood. 

MYOCARDITIS. 

Myocarditis is rarely a primary disease. In most cases designated 
as such it is probable that the underlying affection has escaped detec- 
tion. The acute form, usually of mild degree, and due to the action of 
bacterial toxins, frequently accompanies the acute infectious diseases, 
especially diphtheria, scarlet fever, and sepsis, also typhoid fever, 
influenza, whooping-cough, and pneumonia. 

These toxins appear to affect chiefly the nerves and muscle tissues, 
giving rise to parenchymatous degeneration, while bacteria, such as 
streptococci, staphylococci, and pneumococci, which invade the heart 
by way of the blood stream, seem to attack the interstitial tissues. 
As emphasized elsewhere (page 457), the inflammation of endocarditis 
or pericarditis usually extends more or less to, and affects, the myo- 
cardium, thus producing a real carditis, which affects the whole 
organ. The chronic form is much more rare in children than in adults, 
and causes no arterial degeneration. 

Pathology. — The cardiac muscle is pale in color, soft, and somewhat 
friable. Seen under the microscope, the changes are very distinct, 
round-celled infiltration and granular hyaline fatty degeneration of 
the muscle fiber being apparent. This explains why the weakened 
heart muscle so readily undergoes dilatation. 

Symptoms. — There may be no appreciable symptoms, and death 
may occur very suddenly. When the affection develops during the 
course of an infectious disease, the symptoms are usually indefinite, 
and become more distinct only during convalescence. At this period 
the clinical picture of the acute infectious disease masks wholly or 
in part the symptoms and physical signs of the associated myocarditis. 
The first and most characteristic sign is a persistently irregular pulse, 
either more rapid or slower than normal. This is especially significant 



470 DISEASES OF THE HEART 

during or after diphtheria, scarlet fever, or pneumonia. Later a 
systolic murmur is heard over the apex, the apex beat becomes more 
feeble, the pulse rapid and flickering. 

A child in this condition must be watched most closely, as dyspnea, 
cyanosis, coldness of the extremities, pallor, and restlessness may 
become urgent at any moment, and require the most prompt treatment. 
Usually there is no edema, and pain in the chest and precordial distress 
are comparatively rare. Diminished blood-pressure, weakness of the 
cardiac impulse and heart sounds (the second sound may almost entirely 
disappear and the pulse at the wrist be lost) are danger signals of 
impending cardiac dilatation. 

In fulminant cases diphtheritic myocarditis, purely toxic in origin, 
may cause sudden death during the first few days, or in the second or 
third week, or during convalescence, and as late as the sixth to the 
eighth week. Pallor, cold extremities., cyanosis, vomiting, and syncope 
are ominous signs. In mild cases an irregular pulse on even slight 
exertion may persist for months after recovery. 

The rapid pulse of the first week, and bradycardia during the second 
week of scarlet fever, are in all probability also due to myocarditis. 
Typhoid fever is much less apt to affect the cardiac muscle in children 
than in adults, manifesting itself chiefly by arrhythmia, and rarely 
leads to heart failure. 

Chronic myocarditis sometimes follows the acute form of myo- 
carditis, but develops more frequently after diphtheria. There may be 
tachycardia, more rarely bradycardia, often arrhythmia, and, upon 
slight exertion, dilatation of the heart. The most important symptom is 
increasing muscular insufficiency, just as in the later stages of chronic 
valvular disease. 

Diagnosis. — This is doubtful, especially during the febrile period of 
infectious diseases, in which case the abnormal pulse is often due to 
vasomotor disturbance or an affection of the nervous system. Increased 
cardiac dulness with acute nephritis, which follows scarlet fever, for 
example, might be mistaken for that of myocarditis if it were not for 
the hardened pulse. Diagnosis is mainly based upon an irregular and 
weak pulse following infectious disease, upon sudden attacks of cyanosis 
and collapse, and upon a weak and impure first sound while the 
second may be almost lost. 

Prognosis. — This is always doubtful; an advanced case seldom 
permanently improves. Early and sudden death is almost invariably 
to be expected, especially in diphtheria, unless the most careful treat- 
ment can be instituted early; this should be continued for months or 
for years. 

Treatment. — The treatment of chronic myocarditis is purely symp- 
tomatic, and is directed to lightening the work of the heart and over- 
coming the disturbed circulation. When it follows even a mild attack 
of an infectious disease, absolute rest in bed is necessary. The child 
should not be allowed to lift its head from the pillow, a trained nurse 
should be constantly on the watch to prevent any physical exertion or 



MYOCARDITIS 471 

mental excitement. Needless to say, that even the child's struggles 
against certain forms of treatment may be detrimental. 

A warm sponge bath should be given daily, and a daily movement 
of the bowels without straining be secured. No alcohol or coal-tar 
derivatives are allowable, for fear of further damaging the already 
hampered heart. In older children an ice-bag applied over the heart, 
if not objected to, may give relief. Easily digested food should be 
given in small quantities at frequent intervals, so that there will be no 
distention of the stomach by either food or gas; a liquid or semi- 
liquid diet, containing not too much fluid, answers best. 

For the cardiac weakness digitalis is usually of little use. When 
the pulse becomes weak, and dyspnea and cyanosis appear, camphor- 
ated oil may be given subcutaneously in doses of ten to twenty minims. 
Caffein sodium salicylate or caffein sodium benzoate may be adminis- 
tered hypodermieally in 1 -grain doses, three times a day, to a child 
three to five years old; strychnine, •,,',,, of a grain for a child one year 
old, and double this dose at three years, can be repeated three or four 
times daily, and may be pushed even to its physiological effect — slight 
twitching of the muscles of the face and extremities; adrenaline — 30 to 
40 minims of a ytoif solution in normal saline — may be given three to 
six times daily subcutaneously. It is probably best to give a com- 
bination of several of these drugs, although in somewhat smaller doses. 

How long should a convalescing child be kept under strict observa- 
tion? It should stay in bed as long as the pulse is irregular, or more 
rapid than normal. When the heart seems to be regular, the head may 
be raised by the addition of an extra pillow, subsequently the shoulders 
and head may be elevated until, guided by the cardiac action, the 
child may be allowed to sit up, then to stand up, and finally to walk. 



CHAPTER XVI. 
DISEASES OF THE BLOOD. 

THE BLOOD IN INFANCY AND CHILDHOOD. 

The blood of an infant or child shares the instability of the pulse, 
temperature, and respiration which is characteristic of childhood. 
Just as some slight disturbance will give a hyperpyrexia with very 
rapid pulse in a child, so are grave anemias and high leukocyte counts 
resultant from causes which would scarcely alter the blood of an 
adult. This exaggerated response, which occurs whether the cause be 
pathological or physiological, is due to the as yet incomplete establish- 
ment of the function of producing blood, further shown by the slow 
regeneration of the cellular elements after hemorrhages and the 
prompt appearance of abnormal red and white cells whenever the 
blood-forming organs are taxed. The fact that certain toxins are 
acting on the child's blood for the first time, must also be taken into 
consideration. With this knowledge in mind, we consider the blood 
findings in early childhood far less significant than in adult life. 

Physical Properties. — Color. — The infant's blood is darker for the 
first few days, but quickly assumes the normal color. 

Reaction. — The reaction is always alkaline. 

Specific Gravity. — Specific gravity is about 1.065 at birth and 
fluctuates till the end of the first year when it reaches the normal level 
of about 1.055. The specific gravity is uninfluenced by the number of 
cells or other causes, such as food, rest or exercise, but is in direct 
proportion to the amount of hemoglobin. 

Hemoglobin. — There is a greater amount of hemoglobin at birth 
than in adult life due to a higher percentage in the individual red cell, 
the amount ranging from 104 to 110 per cent, of that found in adult life. 
This higher percentage sinks quickly after birth and at six weeks 55 
to 65 per cent, is normal with proportionate color index. From the 
sixth month to the second year, it is lower than in adult life, and, in 
the normal child during this time, it may go as low as 60 per cent, and 
is rarely above 80 per cent.; then there is a steady rise till, at six 
years, it reaches normal adult percentage. As a general rule, the 
percentage of hemoglobin is higher in boys than in girls. In all the 
various forms of anemia, the amount of hemoglobin is reduced. 

Red Cells. — The number of erythrocytes is increased at birth and 
counts run as high as 8,000,000. They remain high for about twenty- 
four hours, but begin to diminish the second day. Throughout 
childhood the number of oscillations in twenty-four hours is greater 
than in the adult. A few nucleated red cells may be seen at birth, 
but these disappear in the course of a few days; they are rarely found 



THE BLOOD IN INFANCY AND CHILDHOOD 473 

in the blood of normal children but are common in premature infants. 
Erythrocytes vary greatly in size, shape, and staining reaction; they 
are particularly susceptible to structural damage from trivial causes. 

Normoblasts are normal-sized erythrocytes with a dark staining 
nucleus. They are found in both mild and severe anemias, in disease 
of the bone marrow and in severe leukocytosis. 

Megaloblasts are very large red cells, 10 to 20 micromillimeters (/x) 
in diameter, with nuclei of various shapes and polychromatic. They 
occur in very young infants and in pernicious anemia, and indicate 
blood regeneration. 

Microcytes are small red cells from 4 to 10 m in diameter. They 
are seen in chlorosis and severe anemias. 

Poikilocytes are irregular shaped cells occurring in severe anemias. 

The number of red blood cells is diminished in both primary and 
secondary anemias. The red cells are increased during cyanosis, at 
the sea coast and in high altitudes. 

Leukocytes. — There is a physiological leukocytosis at birth averaging 
20,000 to 30,000, followed by a rapid reduction to about 12,000 during 
the next ten days. At the end of the first year, they average 9000 in 
number, and vary between 0000 and 12,000 during childhood. 

Normal Varieties. — The following types are seen normally in the 
child's blood: 

Small Mononuclears. — These comprise 40 to 60 per cent, of the 
leukocytes in the blood of children. They are the size of a red corpuscle 
and have a large deeply staining nucleus. 

Large Mononuclears. — This variety is two or three times larger than 
the small lymphocyte and has an oval nucleus not exactly centrally 
placed, which stains faintly. It comprises from 4 to 18 per cent, of 
leukocytes in children. 

Poh/nuclcars. — These cells are smaller than the large lymphocytes, 
and the nuclei stain deeply with basic dyes. The nucleus has the 
appearance of being composed of several parts joined together. The 
protoplasm of the cell contains small granules which stain with neutral 
dyes. While these cells make up 60 to 70 per cent, of the total number 
of leukocytes in the adult, in childhood they average from 20 to 40 
per cent, of the white cells. 

Esinophiles. — These resemble polynuclears but the granules are 
larger and stain deeply with acid dyes. They average 2 to 4 per cent, 
of the leukocytes in childhood. 

Mast Cells. — This name is given to leukocytic cells whose granules 
stain only with basic dyes, not at all with triacid. They may be 
either mononuclear or polynuclear, and are never seen in early child- 
hood. They are differentiated from the finely granular basophiles 
as follows: The mast cell has a pale nucleus which is usually single 
and may be indented and takes basic stain very faintly, while finely 
granular basophiles are darker and lobed or polynuclear, the nuclei 
taking a moderate amount of basic stain. The finely granular baso- 
phile is the size of a polyneutrophile, while the mast cell is much larger. 



474 DISEASES OF THE BLOOD 

Pathologic Forms. — Myelocytes have a single rounded nucleus and 
contain neutrophilic granules. There is also a non-granular type 
observed in severe anemias. 

Mononuclear eosinophiles appear in the pathological blood. They 
resemble poly nuclear eosinophiles and are called eosinophilic myelocytes. 

Leukocytosis. — In adults, leukocytosis is practically always caused 
by an increase in the polynuclear cells, but in childhood there is a 
greater tendency for the lymphocytes to increase, as is seen in per- 
tussis, hereditary syphilis, scurvy, and rachitis. 

A polynuclear increase in children indicates the presence of actual 
pus formation, septicemia, or severe intoxication. It also occurs in 
pneumonia and diphtheria. A physiological increase follows cold 
bathing, eating, exercise, and massage. An eosinophilia is noted in 
certain cases of chronic skin diseases and is also seen when there is 
infestation by intestinal parasites. 

Leukocytes may be practically unchanged as to number in measles, 
mumps, German measles, and most forms of tuberculosis in children. 
Actual lymphocytosis in acute infections of childhood sometimes 
resembles the blood picture of acute lymphatic leukemia. 

A leukopenia is a diminution in the number of leukocytes and is 
frequently observed in cases of malnutrition, the latter weeks of 
typhoid fever, certain forms of pure tubercular infection, and various 
anemias. 

A normal leukocyte count, or a leukopenia in a disease which usually 
produces a leukocytosis, indicates an overwhelming infection with no 
reaction on the part of the patient, and justifies an unfavorable 
prognosis. 

The diagnostic value of leukocytosis, in a few of the commoner 
diseases of children, is emphasized below: 

Diphtheria. — There is a marked leukocytosis in most cases, and, 
although there is no direct ratio between the degree of leukocytosis 
and the clinical findings, the most severe cases are accompanied by the 
highest leukocyte counts. The presence of myelocytes is regarded 
by some observers as a fatal prognostic sign. 

Empyema. — A rise in the leukocyte count during the course of, or 
following a pneumonia, with no changes in the lungs to warrant it, 
is strongly suggestive of a beginning empyema. 

Meningitis. — Septic meningitis is always accompanied by a leuko- 
cytosis. Cerebrospinal meningitis causes a leukocytosis in most cases, 
but in the tubercular form it is by no means constant, and, if present, 
only to a slight degree. 

Pertussis. — From the very onset of this disease, there is usually a 
high leukocytosis, especially under five years. 

Pneumonia. — There is a marked leukocytosis in pneumonia which 
increases from the onset of the disease to the crisis, when it falls 
rapidly. The usual count is from 20,000 to 30,000, although it fre- 
quently reaches 50,000 and may go above 100,000. A low leukocyte 
count is against a pneumonia, but when it occurs it is an ominous sign. 



ANEMIA 475 

Tuberculosis. — There is no increase in the number of leukocytes 
unless a mixed infection exists. 

Scarlet Fever. — A leukocytosis is present which reaches its maximum 
on the second or third day of the disease, and is of value in 
differentiating this disease from measles. 

Blood Platelets. — These are small colorless cells, usually found in 
clumps, and have no known significance, except that thrombi are more 
apt to form when they are increased. 

Blood Dust. — This is the title given to the colorless granules ranging 
up to 1 ju in diameter, found in normal blood. They are highly 
refractile and possess a dancing motion, but their function has not 
been discovered. 

ANEMIA. 

In childhood, as in adult life, we have two forms of anemia, the 
primary and secondary. 

Secondary anemias are more common and much more easily pro- 
duced in children, frequently reaching an alarming degree. Primary 
anemias are rare, and the distinct types are less clearly defined. 

Secondary or Simple Anemia. — Secondary anemia is that condition 
of the blood in which the changes found are the result of disease, poor 
hygiene, or other causes acting on the general system and causing an 
impoverishment of the blood, the blood-forming organs being involved. 

Etiology. — Hemorrhage is very apt to produce a well-marked 
anemia in children, if at all severe or prolonged. Malnutrition is the 
common cause of anemia in infancy. Anemia follows many of the 
acute infections, the severity depending on the previous condition of 
the child and the intensity of the disease. Syphilis, tuberculosis, 
rachitis, malaria, and scurvy all produce a secondary anemia. Poor 
food, lack of fresh air, prolonged grief or worry and severe mental 
strain are other important factors. The poor physical condition of a 
mother during gestation may be responsible for an anemic child. The 
administration of certain drugs and the action of certain toxins gener- 
ated within the body cause anemia. Children with chronic heart 
disease or nephritis are usually anemic. 

Symptoms. — Pallor of the skin and mucous membranes and pearly 
white conjunctiva are the common visible signs. The child may or 
may not be emaciated, but is listless, languid, fatigues easily, has a 
poor and capricious appetite, and is apt to be irritable and restless. 
Headache, fainting spells and hemorrhages from the nose or other 
mucous membranes are frequent. Enuresis is common and edema 
may be present in the dependent tissues with no albuminuria. This is 
due to the poor circulation, which also causes the child always to feel 
cold, and to become cyanotic and dyspneic on exertion. The heart 
sounds are weak and, after the third year, hemic murmurs are usually 
present. Fever is not constant, but the child is subject to repeated 
and prolonged chills. The spleen is usuallv enlarged — the liver may 
be. 



476 DISEASES OF THE BLOOD 

Blood Picture. — The blood changes are much more marked in the 
secondary anemia of children than in adult life. If the anemia be 
a mild one, there may simply be a reduction of the hemoglobin and 
red cells, generally with a leukocytosis. The blood of the infant or 
very young child easily reverts to the embryonal type and the presence 
of microcytes, megalocytes, normoblasts, and megaloblasts, is noted. 
Poikilocytosis and polychromatophilia are frequent. The hemoglobiu 
may fall to 20 per cent, or even below, and the red cells be less than 
1,000,000 in severe cases. The average anemic child has a hemoglobin 
content of from 40 per cent, to 50 per cent., with the red cells about 
half their normal number. 

Diagnosis. — The diagnosis is quite simple if the etiological factor is 
apparent, but in the absence of a known cause it is difficult. The 
blood picture may reveal many of the embryonal types of cells with 
an indifferent cell count, and render the differentiation between a 
severe secondary anemia and one of the primary anemias impossible. 
Under treatment, however, the secondary anemia usually improves, 
while the primary anemia progresses in spite of all remedial measures. 

Prognosis. — The prognosis depends on the severity of the anemia 
and the cause. Leukocytosis is regarded as a bad sign. The presence 
of pathological red cells, a high color index, and very low hemoglobin 
content or red cell count indicate a severe grade of anemia in which the 
outcome is apt to be unfavorable. 

Treatment. — Unless the case be very severe, the removal of the cause 
soon results in a marked improvement and return to normal. Fresh 
air, good hygiene and nourishing food are absolutely necessary. Iron 
is perhaps the one best drug, and is given to young children and in- 
fants, preferably, in the form of the saccharated carbonate, albuminate 
or peptomanganate. Iron citrate is far more effective when given 
intramuscularly than when given by mouth. One to 2 grains may be 
given daily and will cause a rapid and lasting increase in the hemo- 
globin and number of erythrocytes. No untoward effects occur if 
the injection is given carefully and all forms of anemia respond very 
well to this treatment. Older children may be safely given the same 
preparations as adults. Arsenic, in the form of. Fowler's solution, 
may be given advantageously, where iron is not tolerated, or in 
conjunction with the iron. 

The Primary Anemias. — By the term primary anemia, we mean those 
conditions of the blood due to changes in the blood-forming and blood- 
destroying organs and tissues of the body. Primary anemias are very 
rare during childhood. 

Chlorosis. — Chlorosis is a primary anemia of gradual onset and 
runs a chronic course in which relapses are common. It is char- 
acterized by a reduction of hemoglobin wholly disproportionate to the 
diminution of the red cell count. 

Etiology. — This is a disease of late childhood, occurring about 
puberty. Although a few cases have been reported before the fifth 
year, these are probably cases of chlorotic blood and not true chlorosis. 



ANEMIA 477 

It is usually seen in girls, particularly of the blonde type; rarely in 
boys. Heredity is regarded as a possible factor. The exciting cause 
is unknown, but overwork, close confinement, undernourishment, and 
poor hygienic conditions predispose to it. Psychical elements, as 
shock, grief, care, fright and excessive mental strain should not be 
overlooked. Clark's view, that auto-intoxication is largely responsible, 
is supported by the frequent history of constipation elicited in these 
cases. 

Pathology. — Postmortem findings have shown a hypoplasia of the 
heart and large vessels, and occasionally of the uterus and ovaries. 
There is usually a fatty degeneration of the heart muscle, and the right 
heart may be dilated with hypertrophy of the left ventricle. Death, 
if it occurs, is generally due to a complicating tuberculosis or round 
ulcer of the stomach. 

Symptoms. — The symptoms are those of a simple anemia. Dyspnea, 
palpitation, attacks of vertigo, and syncope are common. The appe- 
tite is poor and frequently perverted. Constipation is the rule. 
The menstrual periods may be very painful and amenorrhea is gen- 
erally present, probably as a result rather than a cause of the disease. 
Enteroptosis and hyperacidity are often found. The heart may show 
evidence of right-sided dilatation and hypertrophy of the left ventricle. 
A hemic murmur, systolic in time, is heard over the mitral and pul- 
monic areas. There is a venous hum in the neck with palpitation in 
the jugular veins. Thrombosis is more apt to occur in the femorals. 
The pulse is soft and weak. Headache, neuralgia, hysteria and 
chorea are among the nervous manifestations. There may be edema 
of the feet, puffiness of the face, and occasionally albuminuria. This 
disease is also called "green sickness" because of the yellowish-green 
tinge of the skin. Pigmentation is occasionally noted. There is 
apparently no emaciation and the patient may look plump and healthy. 

Blood Picture. — The gross changes in the blood are the pale color, 
rapid coagulability, and low specific gravity. Under the microscope, 
the blood shows a moderate decrease in the number of red cells, the 
count ranging from 4,000,000 down to 1,000,000 — rarely below. 
Nucleated red cells are common, normoblasts predominating; megalo- 
blasts never occur. Each individual red cell is pale, smaller, and one 
is occasionally deformed. There is no leukocytosis, but a lymphocyto- 
sis with absolute diminution of poly nuclear s. The hemoglobin is 
greatly reduced, frequently as low as 35 per cent, to 40 per cent. The 
color index is low. The blood platelets are markedly increased, 
perhaps accounting for the shortened coagulation time. 

Diagnosis. — The color of the skin and the blood picture are char- 
acteristic. Age, sex, and the functional derangement of the heart are 
of additional help. 

Prognosis. — The prognosis in uncomplicated cases is uniformly 
good; death, if it occurs, is usually due to a complicating tuberculosis 
or gastric ulcer. The average case lasts a year; exceptionally, cases 
will go on for several years. 



478 DISEASES OF THE BLOOD 

Pernicious Anemia. — This is the most severe form of anemia known. 
It pursues a progressive course, accompanied by constant blood 
changes, and rapidly goes on to a fatal termination. 

Etiology. — It is not a common disease in early life, and the greatest 
number of the cases in children occur in later child life. No specific 
cause has been discovered, and the nature of this disease is as yet 
unknown. Syphilis, rachitis, and infestation by intestinal parasites 
have been observed in some cases. Others have followed a severe 
simple anemia or a grave nutritional disturbance. There is unquestion- 
ably a red cell destruction and that this is a toxic hemolysis is very 
probable. It is believed that these toxins are absorbed from the intes- 
tinal tract, and the peculiar deposits of iron in the hepatic cells have 
led to the theory that most of this red cell destruction occurs in the 
liver. 

Pathology. — There is a severe anemia of all the viscera. Fatty 
degeneration is particularly marked in the heart, bloodvessels, liver, 
and kidneys. Capillary hemorrhages of the viscera and skin are 
common. The heart is larger than normal, and very flabby. The 
liver is enlarged, and histological findings of iron pigments in the liver 
cells are characteristic. This deposit of iron is sometimes noted in the 
intestinal mucosa. The mucous lining of the stomach is apt to atrophy. 
The spleen is enlarged, as it is commonly found to be in all blood 
diseases of children. The bone-marrow is darker and softer and simu- 
lates the embryonic state, the changes being due to reversion to an 
embryonal type and similar type of hemogenesis. It contains numer- 
ous nucleated red cells. The lymph nodes are enlarged and congested. 
Loss of flesh is not constant. 

Symptoms. — The patient, while not emaciated, is very weak and 
frequently prostrated. The skin and mucous membranes are pale. 
The onset is very gradual and may be accompanied by no symptoms 
until the disease has progressed fairly well. There are disturbances 
of digestion, causing nausea and vomiting. The heart may be dilated, 
hemic murmurs are common, and the pulse is soft and full: Dyspnea 
follows exertion and there is restlessness and insomnia. Fever is 
generally present, but it is irregular. The urine is scanty with low 
specific gravity and contains no albumin. Dropsy may appear in 
the dependent tissues, and exceptionally in the serous cavities. Late 
symptoms include epistaxis and hemorrhages from other mucous 
membranes and ecchymoses of the skin. The duration of the disease 
is shorter in children than in adults, usually terminating in less than a 
year. 

Blood Picture. — The drop is very pale, its fluidity is increased, and 
the coagulation time delayed. The specific gravity is low. The 
hemoglobin usually falls below 30 per cent., and at the time objective 
symptoms appear, the red cell count is 1,000,000 or less. During 
remissions, the number of red cells may tend to approach normal, but 
rapidly decreases again in the relapses, so that in the later stages a 
count below 500,000 is not uncommon. Abnormal red cells are abun- 



LEUKEMIA 479 

dant and the megaloblasts exceed the normoblasts in number. Micro- 
blasts are rarely met with. Karyokinesis is common, and the non- 
nucleated red cells are deformed, variable in size, and show poly- 
chromatophilia. Diffuse basophilia, punctate basic degeneration, and 
basic nuclear remains are very common. Rouleaux formation is absent. 
The white blood cells are diminished as a whole, but in infants they 
may be increased. Lymphocytosis, which occurs in the severe cases, 
is accompanied by a diminution in the number of polynuclears. 
Myelocytes, if present at all, are very few in number, and eosinophilia 
is observed where there is infestation by intestinal parasites. 

Diagnosis. — This is based almost entirely on the blood picture, of 
which the following are the distinguishing features: An extremely low 
red cell count, high color index, marked poikilocytosis, the predomi- 
nance of megaloblasts, and lymphocytosis with diminution of poly- 
nuclears. In early infancy, a severe secondary anemia will so closely 
simulate a pernicious anemia that it can be ruled out only by the 
absence of any causative factor. 

Prognosis. — The great majority of cases end fatally. A few cases 
have recovered in which intestinal parasites or rachitis were associated 
and effectively treated. High color index, few normoblasts, and many 
megaloblasts foretell a fatal termination, while an increasing number 
of normoblasts indicates efforts at regeneration and is regarded 
favorably. 

LEUKEMIA. 

This is a disease in which there is a steady and persistent increase in 
the number of white blood cells. The red cells are but moderately 
reduced, although abnormal forms are frequently present. There are 
gross changes in the spleen, lymph glands, and bone marrow. Three 
forms are met with which differ as to the blood picture and pathological 
findings. They are the splenomyelogenous type and the lymphatic, 
which may be acute or chronic 

Etiology. — Children are sometimes the subject of this disease, but 
it rarely occurs in the purely myelogenous form. The lymphatic 
variety is more common, and congenital cases have been reported 
together with several in early infancy. Males are more liable to suffer 
from this disease than females. It may follow the acute infections 
and has been observed in cases of congenital lues, rachitis and malaria, 
but the relation is very obscure. Simple anemia has been followed 
by leukemia and in some cases it occurs primarily in a healthy child. 
Various observers have believed in its infectious nature, or that it may 
be a disease of the lymphatic system, or a later sequence of any anemia 
under certain conditions. 

Pathology. — The spleen, lymphatic glands and bone marrow show 
distinct changes. In the lymphatic form there is a general glandular 
enlargement with slight enlargement of the spleen and liver, and little 
or no apparent change in the bone-marrow. The lymphoid structures 
of the alimentary tract may also be affected. In the splenomyelog- 



480 DISEASES OF THE BLOOD 

enous type, there are marked changes in the spleen and bone marrow, 
and enlargement of the liver. The spleen is greatly enlarged, due to a 
chronic hyperplasia, and may occupy half of the abdominal cavity. 
In the early stages, it is soft and pulpy, and becomes firm and hard 
as the disease progresses, and a perisplenitis usually develops. Lym- 
phoid masses are scattered throughout the body of the spleen, and 
microscopic lymphoid deposits are found in close proximity to the 
arteries. There is a great increase in the number of leukocytes in the 
spleen. The bone-marrow contains a greater number of red and white 
marrow cells, the fat content being reduced. Myelocytes and various 
other cells, including red cells in all stages of development, replace 
the fatty portion of the marrow. The enlarged liver is due to infiltra- 
tion and formation of lymphomata, which cause a marked increase in 
size in either form of leukemia. Other organs are occasionally the 
site of lymphoid infiltration. 

Symptoms. — The onset is gradual, but the progress is rapid and the 
course is apt to be more acute in childhood, although chronic forms 
occur. General weakness with pallor, dyspnea and digestive disturb- 
ances are first noticed. Sight, hearing and the nervous system are 
frequently deranged. Abdominal enlargement or glandular swellings 
may precede any of the above symptoms. Hemorrhages of the 
mucous membranes occur in the nose, stomach and intestines, and 
there may be hemorrhage from the kidney or into the skin. The 
heart shows no symptoms, although the pulse is weak and rapid, and 
attacks of vertigo are common. There is tenderness over the shafts 
of the long bones. Albuminuria occasionally occurs, and there may 
be a varying amount of fever. 

Blood Picture. — The blood is opaque and flows sluggishly, but the 
coagulation time is normal, or but slightly increased. The hemoglobin 
is usually much reduced. The average red cell count is about 3,000,000. 
Nucleated red cells are abundant in the myelogenous variety, but 
rare in the lymphatic. As the disease progresses, the red cells diminish, 
and occasionally fall below 2,000,000. The leukocyte count varies in 
the two forms, being about 50 per cent, greater in the myelogenous 
type where the average count is 400,000. Each variety has a distinct 
blood picture, which enables us to distinguish the three forms. Char- 
acteristic of the myelogenous type is the high number of myelocytes, 
ranging from 30 to 60 per cent, of the white cells. All the intermediate 
forms of leukocytes between the ordinary varieties are present. The 
lymphatic type, if chronic, shows a lymphocytosis made up of about 
90 per cent, small lymphocytes with few myelocytes or eosinophiles. 
Acute lymphatic leukemia is characterized by an increase in the large 
lymphocytes with polynuclears and eosinophiles in very small numbers. 
The other forms of leukocytes are all increased absolutely, but relatively 
decreased. The proportions of white cells to reds may run from 1 to 
15 up to 1 to 3 in the very severe cases. Mixed forms of leukemia are 
met with in children which are neither myeloid nor lymphatic, but 
intermediate between leukemia and splenic anemia of infants. 



LEUKEMIA 481 

Diagnosis. — The diagnosis is based solely on the blood picture. 
The high leukocyte count rules out Hodgkin's disease. The presence 
of pathological forms of leukocytes and red cells differentiates it from 
an ordinary leukocytosis. 

Prognosis. — The disease runs a chronic course. There may be remis- 
sions of symptoms, but the termination is practically always fatal. 

Pseudoleukemia of Infants (von Jaksch). — In the year 1889, Von 
Jaksch first described this disease which is a severe lymphatic anemia 
occurring only in infants. It is characterized by a leukocytosis with 
a decrease in red cells and hemoglobin, and an enormously enlarged 
spleen. 

Etiology. — Practically all cases occur between the sixth and 
eighteenth months. Most of the cases observed have been associated 
with rachitis, and a few with syphilis. Gastro-intestinal disturbances 
have preceded this disease. It has been suggested that it may develop 
from a severe anemia. 

Pathology. — The spleen is greatly enlarged, so that it is often 
apparent to the eye on inspection of the abdomen. On palpation, we 
find it hard and firm due to a hyperplasia. The liver is somewhat 
enlarged, and is firmer than normally. The lymph nodes show 
moderate enlargement. The cellular content of the bone marrow is 
increased. The heart and lungs are negative, the kidneys may reveal a 
degeneration of the parenchyma. 

Symptoms. — Emaciation may or may not be present, although 
anorexia and other gastro-intestinal disturbances are common. The 
skin is pale and waxy and occasionally has a yellowish tinge. Denti- 
tion and closure of the fontanelles may be delayed. Jaundice may 
be present, though not marked. Very often the parents will bring a 
child for treatment of the enlarged spleen, which they themselves have 
noticed. Enlargement of the liver and lymph nodes is generally to 
such a degree that it is noted in clinical examination. 

Blood Picture. — The specific gravity varies between 1035 and 1045. 
The hemoglobin is reduced to below 50 per cent., as a rule, and may go 
down to 20 per cent. The red cell count commonly falls below 
2,000,000, but in some cases it is 3,000,000 and above. Various types 
of red cells are present, of which the nucleated reds are abundant. 
Megaloblasts, microcytes and megalocytes occur, and there is poikilo- 
cytosis and polychromatophilia. Both polynuclear and mononuclear 
leukocytes are increased and eosinophilia may occur. There are 
occasionally a few myelocytes. The total leukocyte count is not as 
high as in true leukemia, and varies between 20,000 and 50,000. In 
but few instances do these cases present definite blood pictures, and the 
summary above merely represents the characteristic findings in the 
few cases so far observed. Polymorphism of leukocytes is the dis- 
tinctive change and a high white cell count suggests complicating 
factors. 

Diagnosis. — The diagnosis rests chiefly upon the blood picture, the 
enormous size of the spleen, and severe gastro-intestinal disturbances 
31 



482 DISEASES OF THE BLOOD 

in a syphilitic or rachitic infant. The lower leukocyte count with 
paucity of myelocytes and the ultimate recovery exclude leukemia. 
Pernicious anemia has a high color index, the red cells are fewer, as a 
rule, and myelocytes do not occur so frequently as in pseudoleukemia 
of infants. The greatly enlarged spleen and presence of myelocytes 
in the blood signify more than a mere secondary anemia. 

Prognosis. — Recovery is the usual outcome; those eases which are 
said to have passed on to a true leukemia were leukemia from the 
onset. With the inception of an intercurrent disease, the prognosis 
should be guarded, as this may cause a fatal termination. 

Treatment of Anemia and Leukemia. — The general management 
of all cases of anemia is the same, since there are certain measures 
which are beneficial to all of the various forms. Fresh air in abundance 
with plenty of sunshine is of distinct importance. Regulation of diet, 
proper hygienic surroundings, and a change of scene and environ- 
ment are of great value. The amount of exercise is governed by the 
severity of the anemia and the strength of the patient. If the anemia 
be of a mild grade, moderate exercise should be advised, but care must 
be taken to avoid fatigue. The severe grades of anemia require rest 
in bed, but this should not exclude fresh air and sunshine. The food 
should contain a maximum of nutrition, but must be given in small 
quantities at frequent intervals, since the gastro-intestinal tract is 
easily disturbed. Due regard to this susceptibility should be given 
in the administration of drugs, for, with digestion and assimilation 
below par or deranged, the treatment of a given case is rendered much 
more difficult. Cod-liver oil, beef extracts, phosphorus and strych- 
nine are used for their tonic effect. Iron and arsenic each has a distinct 
influence in the treatment of anemia, and are given separately or 
together. Iron in the form of the citrate, saccharated carbonate, 
albuminate, or peptomanganate, is borne best by infants, and very 
young children; the chloride is recommended for later .childhood life. 
Arsenic is indicated at times, and should also be given when iron is 
not borne well. Iron cacodylate given by needle is the best form of 
iron in all severe anemias, dose T V to i grain. Arsenic may be given 
with iron, or may alternate with it. Fowler's solution is perhaps 
the best preparation and should be administered in ascending doses 
to the point of tolerance. In all cases of anemia, although it is very 
difficult at times, an earnest endeavor should be made to ascertain 
the cause, for, if this be found, and removed before the anemia has 
reached a fatal degree, prompt recovery will usually ensue. 

Secondary Anernia. — If this is due to hemorrhage, it must be met 
promptly by stimulation of the patient, warm applications, auto- 
transfusion and salt solution intravenously, subcutaneously, or by 
rectal irrigation. When due to disease or other conditions, the cause 
should be removed as quickly as possible, and the general treatment, 
as outlined, should be carried out. 

Chlorosis. — Iron is perhaps the best drug for this condition and 
should be given whenever tolerated. Arsenic may be resorted to if 



SPLENIC ANEMIA 483 

the patient cannot take iron, or may be used with iron. The general 
management is essentially the same for all anemias. 

Pernicious Anemia. — In addition to the general management, 
other measures, such as continued inhalations of oxygen and removal 
to the seashore or mountains, should be resorted to. Arsenic is of 
more value in this disease than iron. Glycerinized extract of red bone- 
marrow has been given, but with indifferent results. Stimulants must 
frequently be resorted to because of the extreme exhaustion and weak- 
ness present. Intestinal parasites should be looked for and disposed 
of. Recently salvarsan has been given with good results, and 
splenectomy has been resorted to in severe cases. 

Leukemia. — The treatment of leukemia is largely symptomatic. 
The general management should be carried out. Here again arsenic 
is the best drug, and should be given up to the point of tolerance. 
X-ray treatment of the spleen has been abandoned, and splenectomy 
in this disease is fatal. Recently the use of the .r-rays upon the 
epiphyses of the long bones has met with promising results, and this 
procedure should be tried. German investigators report good results 
from the use of benzol in leukemia. 

Pseudoleukemia of Infants. — Strict supervision of the diet and careful 
attention to the bowels are necessary. The underlying cause should 
be ascertained and treated. Iron alone or iron and arsenic alternating 
are indicated. Phosphorus must be given cautiously and is of doubtful 
value. 

SPLENIC ANEMIA (BANTI'S DISEASE). 

This is a severe primary anemia accompanied by enlargement of the 
spleen and a cirrhotic condition of the liver. Both red and white cells 
are diminished in number. 

Etiology. — Males are more prone to this disease than females and 
the majority of all cases occur in children and young adults. The 
exact cause has not been discovered. Syphilis is suspected in some 
cases. There exists a theory that the greatly enlarged spleen generates 
a toxin which causes the disease. Most cases occur spontaneously in 
otherwise healthy infants. 

Pathology. — The spleen may attain a considerable size. The 
liver is smaller and cirrhotic. Edema may be present in the dependent 
tissues with dropsical fluid in the serous cavities. Purpura is occasion- 
ally found. 

Symptoms. — Contrary to the belief of Banti, whose name this disease 
bears, we find the first symptoms to be those of a severe anemia. 
Asthenia is marked and prostration is common. Enlargement of 
the spleen soon becomes apparent, and the organ itself is apt to be 
painful. The heart sounds are soft and weak and there is a hemic 
murmur. Edema and ascites are evident as the disease progresses, 
and hemorrhage may occur in the stomach, intestines, or kidneys. 

Blood Picture. — Hemoglobin is markedly reduced to 50 per cent, or 
below. The red cell count rarely falls lower than 3,000,000. Poikilo- 



484 



DISEASES OF THE BLOOD 



cytosis and the presence of normoblasts may be noted. There is a 
lymphocytosis, but an actual leukopenia. 

Diagnosis. — The enlarged spleen is suggestive of leukemia, but this 
is ruled out by the blood findings, which show a leukopenia. Splenic 
anemia, because of its rarity, should be considered only after careful 
study of the case excludes a chronic suppuration, syphilis, or tuberculosis. 

Prognosis. — The prognosis, in cases not properly treated, is grave, 
and the disease runs a more rapid course in children than in adults. 
The treatment is radical, and for this reason quite a few cases are lost. 




Fig. 33. — Banti's disease in a child aged seven years. 

Treatment. — Splenectomy is, at present, the only treatment that 
gives results. This is often a dangerous undertaking owing to the 
severe grade of anemia which is present, but should not be deferred, 
and transfusion, preferably direct, should precede the operation. 



LYMPHATIC ANEMIA (PSEUDOLEUKEMIA: HODGKIN'S DISEASE). 

Primarily, this is a disease of the lymph structures, but it is discussed 
with blood diseases to distinguish it from true lymphatic leukemia. 
It is characterized by persistent enlargement of the lymph glands and 
spleen, and the formation of lymph nodules in the spleen, liver, and 
kidneys. As the disease progresses, a secondary anemia is induced. 

Etiology. — It is a disease of early life, although few cases occur 
before the tenth year. It is more common in boys than in girls. The 
exact cause is unknown, but syphilis, malaria and rachitis are regarded 



LYMPHATIC ANEMIA 485 

as predisposing factors. Tuberculous involvement of the affected 
structures is a complication rather than the primary cause. No acute 
infectious agent, which gives rise to Hodgkin's disease, has been found, 
although this probability is often advanced. The patient is frequently 
in apparent good health at the onset of the disease. 

Pathology. — There is hyperplasia of all the lymphatic structures of 
the body. Both the superficial and deep lymphatic glands are 
enlarged, and, quite commonly, one set of glands in particular will be 
greatly hypertrophied. This occurs most often in the neck. In the 
absence of secondary infection, these enlarged glands do not break 
down and are not adherent to the surrounding tissues. The micro- 
scopic examination of sections from these glands reveals marked 
changes which distinguish them from the enlarged glands of lymphatic 
leukemia, tuberculous adenitis, and lymphosarcoma. There is no 
leukocytic infiltration, although eosinophiles may be numerous. There 
is a proliferation of endothelial cells, with the formation of lymphoid 
and giant cells. An increase of the connective-tissue stroma is observed 
in the more advanced cases, which accounts for the hardening of the 
glands. The spleen is enlarged, sometimes to a great extent, and 
contains lymphatic nodules. The liver and kidneys are also increased 
in size, and the site of lymphoid deposits. The bone-marrow may show 
changes, and lymphoid tissue may be present. Skin tumors are 
occasionally seen. No specific organism has been isolated from the 
enlarged glands of Hodgkin's disease, but many observers have found 
a diphtheroid bacillus. 

Symptoms. — Enlargement of the superficial lymph glands, usually in 
the neck, is commonly the first complaint. Other glands quickly 
show enlargement, but they are not painful. With the progress of 
the disease, enlargement of the spleen and liver, with an increasing 
anemia, occurs. The patient grows weaker rapidly and complains 
of headaches, vertigo, palpitation, and dyspnea. The circulation 
becomes poor, and edema occurs in the dependent portions of the 
body. Gastro-intestinal disturbances follow with constipation, as a 
rule, and sometimes nausea and vomiting. Ecchymoses of the skin 
and hemorrhages from the mucous membranes occur. Fever is 
irregular and subsides during remissions. Cachexia develops late, and, 
commonly with it, various symptoms from pressure of the enlarged 
glands on nerves and vessels (Figs. 34 and 35). 

Blood Picture. — Early in the disease the blood may show no change, 
but with the onset of the secondary anemia there is a steady fall in 
hemoglobin. The color index is low since the red cells are not decreased 
in proportion to the hemoglobin. There is no increase in white cells 
in uncomplicated cases, but there may be a lymphocytosis. 

In the event of a complicating tuberculous infection of the glands 
there is a tendency toward high leukocyte counts which, if the process 
be mixed, as it often is, affects chiefly the polynucleated types of cells. 

Diagnosis. — The diagnosis is based upon the enlargement of the 
lymph glands, their histological structure, and the accompanying blood 



486 



DISEASES OF THE BLOOD 



picture. The structure of the enlarged glands and their movability 
eliminate lymphosarcoma. Tuberculous adenitis generally goes on to 




Fig. 34. — Hodgkin's disease. 




Fig. 35. — -Hodgkin's disease. 



suppuration, and there are usually other foci of tuberculosis present. 
Leukemia is excluded by the blood findings. No positive conclusion is 



HEMORRHAGIC DISEASES 487 

justified without a careful microscopic study of an incised section of 
a gland. 

Prognosis. — Since there is no successful remedial procedure known, 
the prognosis is uniformly bad. The disease is fatal in from a few 
months to three or four years at the longest. Death finally comes on 
from exhaustion with general edema, hastened sometimes by a com- 
plicating tuberculosis. 

Treatment. — Few measures give any relief and those which have any 
appreciable effect are only temporary in their results. Hygienic 
surroundings, fresh air and good food exercise their beneficial influence. 
Arsenic, in the form of Fowler's solution, is most widely used. Tonics 
containing iron, strychnine, cod-liver oil, and quinine are recommended. 
Phosphorus may be given cautiously in doses from Yihr to tttu °f a 
grain. Glandular extracts and bone marrow have been given with 
indifferent results. Local applications bring temporary relief. It is 
claimed that the Roentgen rays influence certain selected cases. Sur- 
gery is of no avail except that it may be resorted to early for the 
removal of a chain of enlarged cervical glands. 

HEMORRHAGIC DISEASES. 

In this group of blood diseases we include those with hemorrhage 
as the dominating feature, and caused solely by changes in the blood 
or circulatory apparatus. Hemorrhage, especially in infants, may be 
merely symptomatic of an anemia, syphilis, scurvy, or the various 
infectious diseases. The etiology of the true hemorrhagic diseases, 
however, is obscure, and their infectious nature or endogenous toxic 
origin is not yet proven. An overabundance of blood and a lessened 
coagulability of the blood have also been suggested as possible causes. 
These diseases are classified as hemophilia, which has a persistent ten- 
dency to hemorrhage and a distinct hereditary basis; and as purpuras, 
in which the tendency to hemorrhage is only transitory. 

Hemophilia (Bleeder's Disease). — This is an inherited disease in 
which the individual shows a disposition to alarming and persistent 
hemorrhage from trivial abrasions or lacerations and spontaneous 
bleeding from no demonstrable cause. 

Etiology. — The hereditary nature of this disease is well established 
and very rarely does a case present itself where this may not be brought 
out. The transmission of this disease is, moreover, along definite lines. 
In a family of bleeders, the female members transmit the disease and 
the males manifest it. Thus, a girl whose mother is a bleeder will not 
show signs of the disease, but will transmit it to her children; while 
her brother will be a bleeder himself, yet his children by a healthy 
wife will not be bleeders, although his grandsons, through his daughters, 
may suffer from the disease. The tendency to transmit hemophilia 
is no stronger in a woman from a family of bleeders, who herself is 
a bleeder, than in her sister, who may not be a bleeder. Marriage, to 
individuals who have not the disease, does not check its transmission, 



488 DISEASES OF THE BLOOD 

and more than 50 per cent, of the children in the affected families 
inherit hemophilia. Large families have been the rule in the cases 
studied and traced through generations. It is rarely noticed at birth, 
but most cases are seen during childhood, generally before the second 
year. They usually die of hemorrhage before the tenth year; after 
the twentieth year this disease is exceedingly rare. It is observed 
more often in boys since girls are not, as a rule, actual bleeders. Most 
of the cases reported have been in Germans and Jews. This disease is 
unknown in the tropics, and occurs most frequently in temperate climates. 

Pathology. — The findings at postmortem are vague and indefinite. 
The cause of the fatal hemorrhage may not be found. There may be an 
endarteritis, fatty degeneration of the intima, and thinning of the vessel 
walls. A secondary anemia may be present as a result of the hemor- 
rhages, but the only blood change is a lessened coagulability. 

Symptoms. — The most significant symptom is bleeding of a serious 
nature from slight injury or no apparent cause. This may be a 
severe sudden hemorrhage, or a constant oozing of blood which resists 
all attempts to check it. Such trivial injuries as the extraction of a 
tooth, or even dentition, may give rise to prolonged bleeding of a serious 
aspect; but it is a curious fact that menstruation and childbirth are 
not, as a rule, accompanied by great loss of blood. Spontaneous 
hemorrhages occur and may be preceded by buzzing in the ears, great 
excitement or even convulsions. These hemorrhages, usually of 
mucous membranes, take place in the gums, nose, throat, or bowel. 
Effusion of blood into the joints may be of an acute nature with or 
without fever, or it may be chronic with some limitation of motion 
and even ankylosis resulting. Following these hemorrhages, we have 
symptoms common to hemorrhage from any cause, and if it be a fatal 
one the patient dies from exhaustion. Sometimes death is preceded 
by, or occurs during, a convulsion. 

Diagnosis. — A distinct hereditary history with a personal history 
of unusual loss of blood from trivial accidents makes the diagnosis 
certain. This is practically all the data obtainable in the average case, 
and the lack of other clinical findings excludes other diseases. Blood 
examination rules out anemias and leukemias. Hemophilic blood-clots 
in from two and one-half to five hours, the delay being attributed to 
an excessive antithrombin blood content, due to actual reduction of 
prothrombin, the ultimate factor of which is referable to some altered 
function of the platelets. Scurvy may be suggested, but diet will 
quickly relieve that condition and has no effect on hemophilia. 
Hemorrhages of the newborn are different in nature, and purpuras are 
accompanied by systemic manifestations. 

Prognosis. — The final outcome is death in over 85 per cent, of cases. 
The longer the patient survives, the better the prognosis, and after 
puberty it is good. The death-rate is higher in males than in females. 
Each hemorrhage may be the last, and the patient recovers from one 
only to have another, until the final one, which is suddenly overwhelm- 
ing or absolutely uncontrollable. 



HEMORRHAGIC DISEASES 489 

Treatment. — Prophylaxis is essential, and, with this view, some 
observers have claimed that the women of affected families should not 
marry. The patient should be guarded from birth and carefully 
protected to prevent any abrasions of the skin and mucous membrane. 
Removal to the tropics should always be suggested. Operative pro- 
cedures are contraindicated and only surgical operations to save life 
should be allowed. If operation is imperative, a careful study of the 
coagulability of the blood should precede it, and an attempt made to 
have the coagulation period as near normal as possible at the time 
of operation. This may be accomplished by intravenous or sub- 
cutaneous injections of human blood serum, or, if time permits, thyroid 
extract may be given over a short period. In the event of hemorrhage, 
styptics may be used locally, of which tannic acid and the perchloride 
of iron are perhaps most serviceable. Adrenalin chloride may be 
given internally and applied locally. I have obtained good results 
from the administration of calcium lactate in the dose of 15 grains three 
times daily in a case of persistent epistaxis. Other drugs which should 
be given are: tincture of chloride of iron, Monsel's solution, per- 
chloride of iron, ergot, and sodium sulphate in small but frequent 
doses. Gelatin has been given for hemorrhage of the stomach, but 
the results are very unsatisfactory. Rectal injections of lead acetate 
have been resorted to in intestinal hemorrhage. Sterile gelatin in a 
5 per cent, solution has been given subcutaneously. Blood transfusion 
should be tried and the father's blood be used, if practicable. Human 
serum is preferable, but animal serum may be used, of which normal 
horse serum is perhaps the best. 

Purpura. — Purpura, although a blood disease, is sometimes classi- 
fied under diseases of the skin, because of its chief clinical feature, which 
is the appearance of hemorrhages in the skin. The areas of hemor- 
rhage vary in size from that of a flea bite to large ecchymotic spots. 
At times they may be found in the mucous membranes and also in the 
viscera. 

Etiology. — Purpura is thought to be caused by the action of toxins 
on the blood or circulating apparatus. It is usually secondary, 
sometimes merely symptomatic, but other cases are apparently 
primary. Hemorrhagic disease of the newborn, ileocolitis, jaundice, 
leukemia, primary and secondary anemias, nephritis, scurvy and 
syphilis are largely responsible for this condition. In older children 
it appears with measles, scarlet fever, smallpox, diphtheria and cerebro- 
spinal fever, and renders the prognosis bad. It is common in septi- 
cemia, pyemia, and malignant endocarditis. The administration of 
such drugs as antipyrin, benzoic acid, chloral, chloroform, ergot, the 
iodides and mercurials, mineral acids, potassium chlorate, arsenic, 
belladonna, copaiba, phosphorus, quinine and the salicylates, may pro- 
duce purpuric outbreaks. An attack of purpura may be brought on by 
bites of snakes and insects, and the toxins liberated in ptomain poison- 
ing and jaundice have a similar action. The paroxysms of whooping- 
cough, the removal of splints, or even epilepsy, may cause it. There 



490 DISEASES OF THE BLOOD 

is not the same relation between neurotic conditions and purpura in 
children as in adults, and it is rarely seen in association with such a 
condition before puberty. Purpura occurs in the cachectic states of 
malignancy and atrophy of infancy. It is said to be a disease of young 
life, most cases occurring before the age of fourteen. In a certain 
number of cases no cause is assignable, and these we term primary, 
but the existence of primary purpura is not proven. 

Pathology. — There is either a hemorrhagic exudate, an escape of 
blood by diapedesis or merely a transudation of blood pigment into 
the tissues. Lesions of the surrounding vessels, such as endarteritis, 
and fatty and hyaline degeneration have been found, but they may be 
caused by the underlying factor of the purpura and it is doubtful 
whether they belong to the pathology of purpura. Stasis and embolism 
have been observed in the surrounding vessels, near hemorrhagic 
areas. Visceral changes include enlarged spleen, gastric ulcers, and 
hemorrhage into the adrenals. The blood picture is not characteristic, 
but usually shows a secondary anemia with or without a leukocytosis. 
There may be evidence of hemorrhage into the joint cavities. 

Diagnosis. — The existence of purpura is easily proven, but in children 
the various forms are not clearly defined and a positive diagnosis of 
any one form is not always possible. Scurvy is sometimes difficult 
to differentiate from an attack of purpura. The following forms are 
met with in children ; purpura simplex, purpura hemorrhagica, purpura 
rheumatica, and Henoch's purpura. The fulminating form, purpura 
fulminans, is only a rapidly fatal case of the hemorrhagic type. 

Purpura Simplex. — This form is the mildest variety met with and 
may not be accompanied by any prodromal systemic symptoms. 
The hemorrhages are confined to the skin. 

Symptoms. — If there be any prodromal symptoms, they are slight 
and consist of general malaise, anorexia, headache, and constipation or 
diarrhea. With the appearance of the purpura, which usually consists 
of small lesions varying in size from that of a flea bite to the diameter 
of a lead pencil, there may be nausea and vomiting, and a slight rise in 
temperature. The characteristic feature of the purpura spot is its 
change of color, first to purple, then to brown, and finally by degrees 
to yellow. Successive crops may appear, the first of which is usually 
seen on the legs; the arms are next involved, and the lesions are most 
abundant on the extensor surfaces. The face and trunk are apt to be 
free from the lesions, and if the mucous membranes are involved 
bleeding externally does not occur. 

Diagnosis. — The diagnosis is easily made by the appearance of the 
purpuric spots, with little or no systemic symptoms. Symptomatic 
purpura is eliminated by the absence of any apparent cause, and the 
more severe forms of purpura are excluded by the absence of their 
particular systemic symptoms. 

Prognosis. —This is guardedly favorable. The attack lasts from one 
to four weeks, but relapses are common. 



HEMORRHAGIC DISEASES 



491 



Treatment. — The patient must remain in bed as long as fresh crops 
of purpuric spots tend to appear, for the duration of the disease can 
be prolonged by exercise and even walking about at this period. The 
diet should be light but nutritious, and contain much of fruit acids. 
Mineral acids, astringents such as gallic acid, and hamamelis are 
indicated. Adrenalin chloride and calcium lactate are also used. 

Purpura Hemorrhagica. — This is a more severe form of purpura, 
in which the skin, mucous membranes, and even the viscera are 
involved, and systemic symptoms are marked. 

Symptoms. — Prodromal symptoms are common, and include chilli- 
ness, fever, vertigo, diarrhea, and anorexia. The hemorrhages vary 
in size from petechia to ecchymotic spots \ inch in diameter. These 
may be light or dark red, do not disappear on pressure, and are either 
painful or itch. Free bleeding may occur from any mucous membrane, 
and hemorrhage from the nose, mouth, throat, stomach, bowels, lungs, 
or kidneys has been observed. A hemiplegia has occurred from an 
intercranial hemorrhage in this dis- 
ease. A secondary anemia, often of 
severe degree, is produced by the 
loss of blood, and, as a result, the 
patient complains of dyspnea, pal- 
pitation, headache, backache, and 
may have abdominal pains. A 
typhoid state may ensue with pros- 
tration, dry tongue and mouth, 
insomnia, carphologia, muttering 
delirium, or even coma. This is 
apt to result fatally. When the 
symptoms come on rapidly and 
the patient quickly succumbs, the 
attack is known as purpura fulmi- 
nans (Fig. 36). 

Diagnosis. — The diagnosis is based upon the presence of purpuric 
hemorrhages from the skin and mucous membranes, and severe consti- 
tutional symptoms which may or may not indicate visceral hemorrhage. 
Joint pains are not marked, if present at all, and this, with the absence 
of urticaria, excludes the rheumatic type. A possible hemophiliac 
phase is eliminated by the lack of a family history characteristic of 
the bleeder and the freedom from previous hemorrhage. Abdominal 
crises of Henoch's purpura do not occur. 

Prognosis. — If the case be mild a favorable prognosis may be given 
guardedly. The weak and young usually succumb and the typhoid 
state generally bespeaks a fatal outcome. High temperature and 
copious hemorrhages are unfavorable signs. 

Treatment. — Rest in bed, good hygienic surroundings, fresh air, and 
a light nutritious diet containing an abundance of fruit acids are 
essential. If there is gastric or intestinal hemorrhage, orange juice, 
peptonized milk and gelatin may be given. Fowler's solution is used 




Fig. 36. — Purpura hemorrhagica. 



492 DISEASES OF THE BLOOD 

in severe cases and a tonic containing iron is best for the secondary 
anemia during convalescence. 

Purpura Rheumatica. — Children rarely suffer from this type of 
purpura, which is characterized by the eruption of purpuric spots 
especially about the large joints, by polyarthritis and exudative erythe- 
mata. A possible relation between this disease and rheumatic fever 
is often claimed because of the arthritis and occasional cardiac involve- 
ment, but, in my opinion, several infective or toxic agents may be 
capable of producing it. 

Symptoms. — Preceding the appearance of purpura, there is usually 
slight fever and often sore throat. A polyarthritis follows, which is 
usually in the joints of the lower extremities, and rarely involves those 
of the arms. Urticaria and erythema nodosum are frequently associated 
with the arthritis, and there may be marked edema of the lower extremi- 
ties. The joints are usually swollen and boggy, and are painful and 
tender. The spleen is sometimes enlarged. Albuminuria may occur, 
but the nephritis is mild. Abdominal pain and tenderness are occa- 
sionally observed. 

Diagnosis. — This is easy when a polyarthritis and urticaria 
accompany a purpura with but slight fever and a sore throat. 

Prognosis. — After two weeks a recovery may be expected, but 
relapses may prolong the attack for months. The ultimate outcome 
is good, although the heart may be permanently affected if cardiac 
involvement occurs. 

Treatment. — The patient should be kept in bed and the same hygienic 
and dietetic measures as for purpura simplex should be carried out. 
The polyarthritis should be treated by the internal administration of 
salicylates and by local applications to the affected joints. 

Henoch's Purpura. — Henoch's purpura or abdominal purpura is 
most frequent in children and the symptoms are referable to the skin, 
joints, and abdomen. The skin lesions are usually purpuric, but may 
also consist of circumscribed areas of edema and exudative erythemata. 
The joints of both upper and lower extremities are painful and swollen. 
The abdominal symptoms are gastro-enteric crises of colic, vomiting, 
tympanites, and tenesmus with melena. There may be hematuria 
and albuminuria, with a fatal nephritis. Occasionally there are 
cerebral and pulmonary symptoms. 

Diagnosis. — The abdominal crises occurring in a case of purpura, 
with joint lesions, are indicative of Henoch's purpura. 

Prognosis. — The prognosis is grave where recurrence is frequent; 
the mortality-rate in Osier's series was 25 per cent. 

Treatment. — Rest in bed with the same hygienic and dietetic treat- 
ment as suggested in the other forms of purpura, should be carried out. 
Further treatment is symptomatic. The calcium salts have been used 
where hemorrhages were severe, and atropin is recommended for the 
abdominal pain. Local applications may give relief to abdominal and 
joint pains, and, if the arthritis is marked, salicylates should be admin- 
istered internally. During convalescence iron and arsenic in tonic 
doses are of special value. 



CHAPTER XVII. 
DISEASES OF THE DUCTLESS GLANDS. 

The spleen is very easily affected by disease during childhood, 
and is then more readily palpable, which makes it of greater diagnostic 
value in children than in adults. Its length ranges from 2 to 4 inches, 
according to the age of the child, it is half as wide as it is long, and 
about \ of an inch thick. The size of the spleen varies greatly with 
the state of the nutrition. As a rule, a poorly nourished infant will 
have a very small spleen, but when malnutrition is caused by syphilis 
or rachitis the spleen is enlarged. There is a physiological increase 
in the size of the spleen during digestion, owing to the increased amount 
of blood in the organ at this time. 

The position of the spleen may be made out by percussion with the 
child lying on its back and percussing above downward in the mid- 
axillary line. Splenic dulness will be found to extend from the ninth 
to the eleventh rib and from the posterior axillary line to a little 
beyond the midaxillary line. In infants the area of splenic dulness 
may not be distinguishable, may sometimes be obliterated by gastric 
or colonic tympany, and may be simulated by fecal masses in the colon. 

In order to palpate the spleen the patient should lie on his back with 
the thighs flexed to afford good relaxation of the abdominal muscles. 
The physician's hand should be warmed, and should first be gently 
placed over the splenic area, just at the lower border of the ribs, 
until abdominal rigidity is overcome. The right hand is preferable, 
the examiner standing on the right side of the patient. The finger 
tips are pressed up under the costal margin between the posterior 
and midaxillary lines, when the spleen should be felt touching the 
finger tips with each respiration. The edge of the spleen should be 
felt just under the lower border of the ribs. If it extends below the 
costal margin it is enlarged. 

Enlargement of the spleen may be acute or chronic; in children 
acute enlargement is much more frequent than in adults, since many 
of the acute infectious diseases cause an increase in its size. A 
chronically enlarged spleen is seen in malaria, cirrhosis of the liver, 
the chronic infectious diseases, particularly syphilis and tuberculosis, 
and in chronic congestion caused by cardiac and pulmonary disease. 
The spleen is also enlarged in the various forms of anemia, in Hodgkin's 
disease, gastro-enteritis, acute catarrhal jaundice, and amyloid de- 
generation. 

SPLENITIS. 

Inflammation of the spleen is rare, and when it occurs is generally 
caused by extension from surrounding structures, such as the stomach, 



494 DISEASES OF THE DUCTLESS GLANDS 

diaphragm, lungs, or the perinephric tissue. It may be due to trauma. 
In splenitis the spleen is found to be enlarged, percussion in the splenic 
region is painful, and palpation reveals acute tenderness. The diagnosis 
is based on the symptoms outlined above, with a history of trauma 
or inflammation of surrounding structures. 

PERISPLENITIS. 

Perisplenitis is an inflammation of the serous covering of the spleen. 
It occurs in general peritonitis, and may also be a result of extension 
from an ulcer of the stomach, a left diaphragmatic pleurisy, peri- 
nephric inflammation, or chronic colitis. Trauma, hemorrhagic in- 
farcts, syphilis, and tuberculosis are among the rare causes of peri- 
splenitis. 

The diagnosis is made by detecting the friction rub of the roughened 
capsule. On auscultation the friction rub is heard better at the lower 
margin of the rib than over the chest wall, and this helps to differentiate 
it from a pleural friction rub. In some cases the spleen may be immov- 
able owing to adhesions. 

ABSCESS OF THE SPLEEN. 

This is a rare condition in children, but may arise from trauma or 
during the course of malaria, typhoid fever, or pyemia. It may also 
be due to extension from a suppurative process in adjacent tissues. 
When the suppurative lesion reaches the surface perisplenitis results, 
and rupture usually follows, the contents pouring into the free peri- 
toneal cavity or some adjacent viscus. 

WANDERING SPLEEN. 

As the result of elongation of the gastrosplenic ligament and the 
splenic artery and vein, the spleen may attain a wide range of mova- 
bility. When this condition exists there is tympany over the area of 
normal splenic dulness, and abdominal palpation reveals the spleen 
low down in the abdomen, but usually on the left side. As a rule it 
can be replaced, but when the patient assumes the upright position 
it will again fall out of place. 

The most constant symptom is a dragging sensation in the abdomen. 
The spleen is enlarged, and may produce symptoms by pressure on the 
ureter, bladder, or bowel, and there are usually nervous symptoms like 
those accompanying nephroptosis. The presence of a fecal tumor or a 
floating kidney must be considered and excluded before a positive 
conclusion is reached. The treatment consists of mechanical measures 
to keep the spleen in its proper position, but they are only moderately 
successful. 



SIMPLE ACUTE ADENITIS 495 



PRIMARY SPLENOMEGALY. 

This is a rare form of enlargement of the spleen, which is most 
common in children. The cause is unknown. There is hyperplasia 
of the endothelial cells of the spleen, with changes in the mesenteric 
lymph nodes. The liver is enlarged secondarily, and contains an 
increased amount of connective tissue. There are abdominal pains 
and gastro-intestinal disturbances. Simple anemia with subcutaneous 
hemorrhages and bleeding from the gums and nose may be present. 
1 )yspnea and dysuria have been noted. The spleen may attain such 
a size as practically to fill the abdominal cavity. 

NEW GROWTHS OF THE SPLEEN. 

In children the spleen is rarely the site of new growths, but occasion- 
ally the roughened or nodular surface of the spleen will warrant their 
consideration. Tuberculosis is the most common cause of nodular 
spleen in children. Gummata of the spleen are rare, although the 
enlarged spleen is the most constant sign of hereditary syphilis. 
Leprosy, actinomycosis, and parasitic cysts have been observed. 
Benign splenic tumors are very rare. Of the malignant tumors, 
sarcomas are the most frequently found, and are usually secondary. 
Cancer is extremelv rare. 



DISEASES OF THE LYMPH GLANDS. 

Enlarged lymph glands are much more common in children than 
in adults, and of all the lymph nodes in the body the cervical glands 
are the most frequently enlarged. Pediculosis capitis, or disease of the 
scalp, such as an eczematous condition, causes enlargement of the 
posterior cervical glands. The anterior cervical glands become enlarged 
with disease of the nose and throat, and are also subject to infection 
by the tubercle bacillus. The axillary glands are involved by infection 
of the arm and outer side of the upper chest wall. 

Enlargement of the epithrochlears is seen in syphilis. The inguinal 
glands, which are the only set normally palpable, are enlarged when 
there is a lesion of the genitalia or infection of the leg. General 
glandular enlargement is observed in syphilis, tuberculosis, lymphatism. 
the various forms of anemia, and following acute infectious diseases. 
Children of lymphatic diathesis rarely exhibit it after adolescence. 

SIMPLE ACUTE ADENITIS. 

Children are very susceptible to simple adenitis, which is an acute 
inflammation of the lymph nodes. The cervical glands are the ones 
affected in over 80 per cent, of the cases; they become inflamed by the 



496 DISEASES OF THE DUCTLESS GLANDS 

draining of an infected area, such as a diseased tonsil or a decayed 
tooth. Acute adenitis may complicate the acute infectious diseases, 
and usually appears during tonsillitis or any throat infection. Eczema 
and stomatitis may also give rise to acute adenitis. 

The deep lymphatic glands may become inflamed from draining an 
infected source, but they are not demonstrable, hence only the super- 
ficial glands will be considered. The axillary and inguinal glands 
enlarge when there is infection of those areas of the body which they 
drain. Most cases of simple adenitis occur before two years of age. 
The exciting or direct cause is the entrance of pyogenic organisms into 
the lymph glands. 

Pathology. — The enlargement of the gland is due to hyperplasia of 
lymphoid cells, with acute congestion of the glands. The infection 
may go this far, and then stop, or may proceed to suppuration according 
to the virulence of the organism and the resistance of the patient. 

The streptococcus is usually isolated in those cases which suppurate, 
although the staphylococcus, pneumococcus, gonococcus, and typhoid 
bacillus have also been found. As suppuration takes place the nodes 
become softer and the surrounding tissue infiltrated which causes 
cellulitis. Frequently only one node in a chain of several diseased 
ones will suppurate. 

Symptoms. — Swelling just below the angle of the jaw is, perhaps, 
the first sign of cervical adenitis. The degree of tenderness varies; 
in some cases there is very little pain, while in others merely moving 
the jaw is painful. There is moderate fever, with symptoms of the 
underlying disease if adenitis is caused by one of the acute infections. 
Suppuration takes place between the first and fourth weeks; after 
the fourth week, if there has been no suppuration, resolution may be 
expected to follow the stage of hyperplasia. The glands become 
smaller and harder, and slowly return to their normal size. After 
repeated infections the gland may become chronically enlarged, and 
remains as a palpable nodule throughout life. 

Upon inspection only one or two glands in the chain will appear to 
be affected, but palpation shows the whole chain to be involved. When 
suppuration begins the gland softens, the overlying skin becomes red, 
and tenderness and pain are increased. If not lanced there is pointing 
and rupture through the skin, with the discharge of a creamy pus. 
This relieves the symptoms, and there is slow recovery, with an ugly 
scar at the site of rupture. 

Diagnosis. — Acute adenitis may simulate mumps, but in mumps 
the swelling is in the parotid region, the lobe of the ear forming the 
centre of the swelling. In mumps there is usually a history of contact, 
and in adenitis a history of some preceding nose or throat condition. 
After two years of age tuberculous adenitis is quite frequent, but 
may be ruled out by its chronicity. 

Treatment. — The cause should be ascertained and removed if 
possible. Careful attention to the throat, especially to the tonsils 
and any adenoids, will prevent most cases of cervical adenitis. Locally, 



SIMPLE CHRONIC ADENITIS V.)t 

cold applications will give relief, and are indicated if there is merely 
congestion and swelling with no suppuration. Cold compresses are 
better than an ice-bag, but should be renewed every fifteen to twenty 
minutes. 

When suppuration becomes inevitable, heat and ichthyol ointment 
should be applied. If there is fluctuation the abscess should be opened 
and drained. A course of calomel should be followed by magnesium 
sulphate, and then syrupi ferri iodidi given in full doses for a period 
of weeks. For those glands which do not suppurate, but which remain 
large and later offer but poor resistance to the tubercle bacillus, the 
iodides, electricity, Bier's hyperemia, or surgical removal may be 
resorted to. 

SIMPLE CHRONIC ADENITIS. 

This is usually a mild degree of enlargement of the lymph glands, 
which persists in consequence of repeated attacks of acute adenitis 
or because the source of infection is still acute. Chronic nose and 
throat conditions and chronic skin or scalp diseases are frequently 
responsible for the persistent enlargement of these glands. As a rule, 
hypertrophied tonsils and adenoids are present, and, possibly, that 
condition known as status lymphaticus. 

Symptoms. — Enlargement of the glands is the main clinical feature. 
Pain and tenderness are absent, and there are no constitutional 
symptoms. The glands may remain enlarged, for months, or even years, 
or may never return to normal, those affected remaining as small hard 
nodules throughout life. Suppuration does not take place in these 
glands, but the centre of the gland may be found to consist of broken- 
down tissue resembling tuberculous caseation. 

Diagnosis. — Simple chronic adenitis must be differentiated from 
tuberculous adenitis and Hodgkin's disease. The absence of any 
clinical features other than enlargement of the glands, the age of the 
individual, and the slow progress of the process usually favor simple 
chronic adenitis. 

If we suspect some specific factor rather than simple chronic enlarge- 
ment of the glands, an incised section examined under the microscope 
will reveal the true nature of the disease. The importance of diagnosing 
a possible tuberculous adenitis early is so great that a section of the 
suspected gland should be made in every case where doubt exists 
as to whether or not surgery should be resorted to. 

Treatment. — Removal of the cause of the enlargement is essential 
before improvement can be expected. Potassium iodide and the syrup 
of the iodide of iron should be given in full doses. Cod-liver oil and 
arsenic in the form of Fowler's solution are both beneficial for their 
tonic effect. An outdoor life, with plenty of exercise and good nourish- 
ing food, will materially hasten the ultimate recovery. In view of the 
fact that these glands, if they remain enlarged, frequently become 
tuberculous, surgical removal should be advised when other treatment 
is of no avail. 
32 



498 DISEASES OF THE DUCTLESS GLANDS 

TUBERCULOUS ADENITIS. 

The term " tuberculous adenitis" is awarded by common usage to 
tuberculosis of the cervical lymph glands. The infecting organism 
gains access to the glands through abrasions or the extension of 
inflammation in the mucous membrane of the nose and throat. 
Diseased tonsils, adenoids, and chronic inflammation of the naso- 
pharynx predispose to the tuberculous infection. 

It is now believed that the bacilli do not penetrate the normal mucous 
membrane, but are carried in with food and air, and obtain access 
through the point of least resistance, which is usually the site of some 
chronic inflammation. In uncomplicated cases the infecting organism 
is often difficult to find. It is usually the human type of the tubercle 
bacillus, although the bovine form has been isolated. 

Suppuration is generally caused by mixed infection with the strepto- 
coccus. Merely one chain of glands or the lymphatics on both sides of 
the neck may be affected. In some cases all of the glands of the body 
may be involved — the cervical first, then the axillary, mediastinal, 
retroperitoneal, mesenteric, and inguinal glands. 

The disease may progress in such a manner as to bear a resemblance 
to Hodgkin's disease. The glands may appear as separate and discrete 
nodes, varying in size from that of a bean to a walnut, or they may 
coalesce. They may be quite hard or almost gelatinous in consistency. 
An incised gland will be found to contain an increased amount of 
connective tissue, with many small areas of necrosis throughout its 
substance. Microscopically, giant cells containing several nuclei 
may be seen; the tubercle bacillus is hard to demonstrate. Caseation 
does not occur in this generalized adenitis. 

Symptoms. — As a rule, there are no constitutional symptoms and 
the health may apparently be unaffected; usually, however, there is a 
gradual loss of weight with mild secondary anemia. If there is second- 
ary infection of the glands, slight fever is noted and the glands are 
painful. Those glands situated at the angle of the jaw first become 
enlarged, and this swelling may be the only noticeable sign of tuber- 
culous adenitis. The swelling is usually unilateral, but may involve 
both sides. 

As the disease progresses the glands become immovable from the 
periadenitis which develops, and adhesions to the surrounding tissues 
form. There is practically no pain in uncomplicated cases. With 
secondary infection and pus formation the usual symptoms of abscess 
are present. 

If the gland is not incised at this stage, the abscess may rupture 
through the skin, or rupture beneath it and the pus burrow down 
through the fascia of the neck, collecting at the most dependent part, 
and there escape through the skin. When this occurs there is a fistula 
between the infected gland and the point where it opens through the 
skin. The whole process is essentially chronic, only the neglected 
cases resulting in ruptured abscesses and fistula formations. 






DISEASES OF THE THYMUS GLAND 499 

Diagnosis. — Tuberculous adenitis must be differentiated, first, from 
simple chronic adentitis. The age of the child, the tuberculin reaction, 
and the presence or absence of other tuberculous lesions must be taken 
into consideration in determining with which of these forms of adenitis 
we are dealing. If lymphosarcoma or pseudoleukemia is suspected, 
a section of the enlarged gland should be examined microscopically. 
Examination of the blood will rule out the possibility of leukemia 
as a cause of the glandular enlargement. 

Prognosis. — The prognosis of tuberculous adenitis is better than for 
any other form of tuberculosis, since the infected tissue is easy of 
access, and the disease tends to remain localized. Systemic infection 
from foci in the glands of the neck is rare, hence the mortality-rate of 
tuberculous adenitis is extremely low. If the case is diagnosed early, 
and its surgical removal undertaken, recovery with complete eradica- 
tion of the disease may be expected. 

Treatment. — Early and complete removal of all the infected glands 
is unquestionably the only safe treatment of tuberculous adenitis. In 
the hands of a skilful surgeon there need be no appreciable scar after 
the operation, although through fear of disfigurement many parents 
will object to operative procedure. Following the operation the patient 
should have the advatage of the routine treatment for tuberculosis 
with, possibly, a change of climate. 

The diet should be wholesome and nutritious, with an abundance of 
eggs and milk. Cod-liver oil is of great benefit, but care should be 
taken that it does not impair the appetite. The syrup of the iodide 
of iron should be given in full doses throughout convalescence, and 
arsenic in the form of Fowler's solution is indicated for the secondary 
anemia which is usually present. 



DISEASES OF THE THYMUS GLAND. 

The thymus gland is a lymphoid structure which exists only during 
childhood, the period of its greatest growth being reached at the end 
of the second year. Atrophy of the lymphoid tissue with an increase 
in the fibrous and adipose tissue takes place gradually from the second 
year until puberty. From puberty on to early adult life there is 
rapid atrophy of the gland, until at adult life there exists merely a 
fibro-fatty body with but faint traces of thymus lymphoid tissue. 
During childhood two distinct lobes may be defined, lying in close 
contact with the pericardium and the trachea. The two lobes are 
unequal in size, but may be said to extend from the lower border of the 
thyroid gland to the level of the fourth costal cartilage. The gland 
lies just beneath the sternum in the chest, and farther up is found under 
the sternohyoid and sternothyroid muscles. The two lobes may be 
united, or there may be a third lobe. The average weight of the thymus, 



500 



DISEASES OF THE DUCTLESS GLANDS 



as given by various observers, offers a wide range, but to the best of 
our knowledge the normal thymus gland should weigh from 7 to 10 
grams (100 to 150 grains) between birth and two years of age. It is 





Fig. 37 



Fig. 38 



Fig. 37. ! — Unilobar thoracic thymus. Newborn infant, death from causes in no 
way referable to thymus. Single-lobed thymus extended from just below interclavicular 
space to diaphragm along right border of heart. Weight 3.75 grams. No other thymic 
tissue found. No evidence of pressure on trachea; position such that trachea could not 
have been compressed. (Coplin.) 

Fig. 38. — Bilobar thoracic thymus. Status lymphaticus thymic death. Male, 
aged fourteen years; asthma of long duration; otherwise in good health. Received 
immunizing dose of antitoxin; death in a few minutes. Notable hyperplasia of many 
lymph nodes. Thymus consists of two tongue-like lateral lobes extending downward 
over heart to diaphragm; no median lobe; weight 17 grams. Upper margin behind 
sternum more than 2 cm. below notch. No evidence of tracheal compression. Upper 
third of each lobe shows wrinkled capsule, fat infiltration and shrinkage — evidences 
of regression. The absence of any isthmus or mass at point of junction precludes 
tracheal pressure. (Coplin.) 

1 Figs. 37 to 45 are published with the permission of Dr. W. M. L. Coplin, and are 
taken from his article on "Morphology of the Human Thymus," Publications from the 
Jefferson Medical College and Hospital, Philadelphia, 1915, vol. vi. 






DISEASES OF THE THYMUS GLAND 



501 



about 12 cm. (5 inches) long and from f to l\ inches (2 to 3 cm.) wide 
when it has attained its largest size. 





Fig. 39 Fig. 40 

Fig. 39.— Trilobar cervicothoracic thymus. Infant; death a few hours after birth, 
not thought to have been due to thymus. Long median lobe extending above sternal 
notch; two imperfectly distinguishable lateral lobes, the inferior margin of which extended 
over anterior part of auricles but not reaching the ventricles. No evidence of pressure 
on vessels or trachea. Weight of thymus 4.14 grams. (Coplin.) 

Fig. 40. — Trilobar cervicothoracic thymus (persistent). Male, colored, aged thirty- 
six years. Hemiplegia, epilepsy, aphasia. Death from cerebral softening. Middle 
or superior lobe abnormally large; lateral lobes about normal for childhood, extended 
from above suprasternal notch to diaphragm. Weight of thymus 7.82 grams. No 
evidence of pressure. Were the superior lobe large, or greatly thickened antero- 
posteriorly, pressure on trachea would be possible. (Coplin.) 



Physiology. — The function of the thymus is not yet understood, 
and we are still in doubt as to whether it should be classed as one of the 
ductless glands or with the other lymphoid structures of the body. 



502 DISEASES OF THE DUCTLESS GLANDS 

It is thought to be connected with the lymph system and the thyroid 
and parathyroid glands. That there is a relation between the thymus 
and testes is shown by the delayed involution of the thymus following 
castration, and the rapid growth of the testes in thymectomized animals. 
Extirpation of the thymus is also followed by softening of the bones 




h 



)■ 



,..■' 






M 



Fig. 41 Fig. 42 

Fig. 41. — Trilobar cervicothoracic thymus. Male, white, aged thirteen years. 
Splenic anemia, greatly enlarged spleen weighing 1100 grams. Splenectomy; recovery. 
Two years later admitted to hospital in convulsions, probably unconscious, face flushed, 
dyspnea, respirations 40, slight cyanosis, rapid heart (100). Temperature 104°; extremi- 
ties cold. History of dog bite. Clinical diagnosis: Status lymphaticus. Postmortem: 
Status lymphaticus; congestion of lungs; adhesive pleuritis; congestion of liver and 
kidneys; hyperplasia of lymphoid tissue of intestine, colon and stomach; enlarged 
lymph nodes ; chronic adhesive peritonitis in splenic area ; adhesions probably due to 
splenectomy. Organ of quite unusual shape, resting upon and overlapping heart and 
extending upward behind sternum just above notch. Weight of thymus 23.61 grams. 
Such an organ might press upon trachea in critical space or beneath sternum. There is 
sufficient evidence to justify the recognition of lobes; otherwise it might be called a 
conglomerate thymus which it in part resembles. (Coplin.) 

Fig. 42. — Conglomerate thoracic thymus. Female, colored, aged twenty months. 
Clinical note: Bronchopneumonia, pleurisy; dyspnea; cyanosis; rapid pulse of low 
tension. Postmortem: Bronchopneumonia, bilateral pleural effusion, partial atelectasis, 
congestion of liver and spleen ; fatty infiltration of liver. Thymus lies over and anterior 
to heart, is thin, of rather flat type, lobes imperfectly and irregularly joined above and 
below. Weight 9 grams. (Coplin.) 

and cessation of their growth, by an increased electrical excitability of 
the peripheral nervous system, increased fat absorption, malnutrition, 
and cachexia. Enlargement of the spleen is followed by shrinking of 
the thymus. Bourneville found the thymus in only 27 per cent, of 
idiots at postmortem. In addition to this relation of the thymus to 




Fig. 43. — Conglomerate thoracic thymus. Female, white, aged one year. Clinical 
diagnosis: Bronchopneumonia. Postmortem: Bronchopneumonia. Patent intra- 
ventricular septum; chronic mitral endocarditis; hypertrophy and dilatation of left 
ventricle. Congestion of liver, spleen and kidneys. Pyramidal ot conic thymus; lobu- 
lation imperfect, somewhat flattened anteroposterior^ ; pale, some edema; organ firm, 
pressure phenomena improbable. Weight of thymus 16.3 grams. (Coplin.) 





Fig. 44 Fig. 45 

Fig. 44. — Conglomerate cervicothoracic thymus. Eclamptic mother died suddenly 
following therapeutic administration of horse serum. Infant (seven months?) obtained 
postmortem; length 46 cm., weight. 2020 grams. Subpericardial hemorrhages; congested 
kidneys; congested, soft, friable liver. Thymus: Two (possibly three) imperfectly 
differentiated lobes with a prolongation extending through critical space to 1.9 cm. 
above superior sternal border; the flattened inferior aspect was just over cardiac base 
upon which, when the auricles were distended, it no doubt rested; left lobe extended to 
near middle of left ventricle. Weight of thymus 8. 1 1 grams. No gross lesion. (Coplin.) 
Fig. 45. — Conglomerate thoracic thymus. Female, aged twenty-four hours. Low 
attachment and partial separation of placenta; Cesarean section. Weight of infant 6^ 
pounds. At birth infant cried naturally, did well for twenty-four hours, died in spasm 
■with dyspnea. Postmortem: Aside from enlarged thymus and changes referable 
thereto, nothing abnormal found. Thymus greatly enlarged, intensely edematous, 
bulges in front and above heart. Body opened and fixed in formalin; thymus dissected 
from bed. Weight of thymus 45 grams. Histologically, richly cellular thymic tissue, 
intensely edematous. Precava and trachea manifestly compressed; trachea collapsed. 
Irregular areas of pulmonary aeration; all anterior margins of both lungs airless; bases 
imperfectly expanded, many lobules atelectatic. (Coplin.) 



504 DISEASES OF THE DUCTLESS GLANDS 

other organs of the body, it has been proven that lymphocytes and 
eosinophiles are found in the lymphoid tissue of this gland. 

Percussion. — The outline of the thymus may be elicited by light 
percussion over the upper part of the sternum in young children, 
but thymic dulness disappears after the second year, after which it is 
pathological. The area of dulness produced by the thymus in children 
is continuous with cardiac dulness, and should not extend more than 
\ inch (1 cm.) beyond the margin of the sternum on either side. 

ATROPHY OF THYMUS. 

The thymus gland is very susceptible to changes in the general state 
of nutrition of the body, and is found to be very small in cases of 
malnutrition. Infants in whom the thymus was so small as t'o be 
considered absent, and in whom the gland did not weigh over 30 grains, 
have been fatal cases of marasmus due to improper feeding, imperfect 
assimilation, congenital lues, rachitis, and chronic tuberculosis. If 
the case be one of chronic toxemia the lymphoid tissue is practically 
altogether replaced by fibrous tissue, while in children dying of 
starvation there is simply an atrophy of all the tissue elements with 
marked reduction in weight. 

ENLARGEMENT OF THE THYMUS. 

Acute enlargement of a normal-sized thymus gland may occur from 
congestion due to cardiac disease or after goitre operations, or as a 
result of hyperemia or edema. This enlargement is occasionally 
sufficient to cause death from pressure on the underlying structure. 
True hyperplasia of the thymus has been observed in cases of congenital 
lues, rachitis, anemia, Hodgkin's disease, chlorosis, leukemia, Addison's 
disease, and exophthalmic goitre. The theory has been advanced that 
enlargement of the thymus is a secondary compensation measure oc- 
curring in infections, auto-intoxications or disturbances of metabolism 
in which there is lymphoid exhaustion. Enlargement of the thymus 
is a part of that rare condition known as status lymphaticus, in which 
there is a general hypertrophy of the whole lymphatic system. 

Pathology. — Postmortem findings in a few cases have shown merely 
congestion or edema to have been the cause of fatal enlargement of the 
thymus. In the majority of cases there is a true hyperplasia of the 
organ, particularly of the lymphoid tissue. Although there is much 
discussion over the weight of the normal-sized thymus, a thymus over 
J ounce (15 gm.) may be considered as enlarged. Of the dimensions, 
increased thickness is of greatest importance, since it results in pressure 
on the underlying structures, particularly the trachea which has been 
found to be flattened, and even stenosed to a considerable degree. 
Pressure on the great vessels may cause hypertrophy and dilatation 
of the heart. Thrombosis of the jugular vein has been found at 
autopsy. 



ENLARGEMENT OF THE THYMUS 



505 



Symptoms. — Enlarged thymus has been observed after death which 
caused no symptoms during life, but, as a rule, there is evidence of 
respiratory difficulty. This interference with respiration may vary 
from mild stridor to severe dyspnea which terminates fatally. Thymic 
stridor is believed to be due to compression of the trachea and is 
usually noticeable at birth, although it may not develop until some 
time after. It is chiefly inspiratory, but expiration is also impeded. 
Attacks of thymic stridor may be induced during one of the acute 




Fig. 46. — An infant with an enlarged conglomerate thoracic thymus in situ. A 
thyroid, slightly below normal position. B, lobes of greatly enlarged thymus. Incom- 
plete separation is into lobes, upper, right and left. The upper is partly divided by 
an incompletely formed vertical depression. The fissures separating the lobes are no- 
where complete. Near the left inferior anterior margin of the right lobe is a small 
partly detached mass of thymic tissue that might be called an accessory lobe. C, heart 
covered by intact pericardium; auricles concealed and compressed by enlarged thymus 
which extends a little lower on the right than on the left side, thereby conforming to 
the base of the ventricles. D, summit of liver. (Case of Dr. E. P. Davis.) 



infectious diseases, or may be precipitated by a fit of crying or scream- 
ing in which the head is thrown backward. These acute attacks, which 
may subside entirely, are probably due to congestion of an already 
enlarged gland. In other cases thymic stridor is constantly present 
and there is an audible respiratory sound, both on inspiration and 
expiration, the voice remaining clear. The intensity of this sound is 
increased during crying or coughing, and is diminished during sleep. 
Aside from the presence of this stridor the child may be practically 



506 



DISEASES OF THE DUCTLESS GLANDS 



well. The child subject to thymic stridor may suffer from acute 
exacerbations in which the difficulty of respiration is markedly in- 
creased, and these attacks are known as thymic asthma. At such a 
time the child appears to be suffocating, the head is thrown back, and 
inspiration is accompanied by retraction of the intercostal spaces 
and the suprasternal notch. The face wears an anxious expression 
and becomes cyanotic and then pale. The extremities are rigid and 
the hands clenched. The pupils dilate, the heart sounds become weak, 
the pulse is lost at the wrist, and the child may die. Recovery from the 
attack may be complete with disappearance of all symptoms, or the 




Fig. 47. — An infant with an enlarged conglomerate thoracic thymus, removed 
(shown just over right shoulder of infant), disclosing cavity occupied. A, compressed 
caVa. B, heart, the flattening of which is well shown. C, summit of liver. (Case of 
Dr. E. P. Davis.) 



stridor may persist. As a rule, repeated attacks occur, growing pro- 
gressively worse until death. Cases of thymic asthma occur in which 
there has been no previous thymic stridor, and thymic death is not 
always preceded by thymic asthma. The term, thymic death, is 
applied particularly to those cases of sudden death attributed to 
enlargement of the thymus in which there has been no previous stridor 
or asthma. 

The question as to whether or not the enlargement of the gland 
itself is the essential pathological basis for thymic death is still in 
dispute, but the preponderance of opinion seems to justify this con- 



STATUS LYMPHATICUS 507 

elusion. The manner in which death is caused by enlargement of the 
thymus has not been proven to the satisfaction of all, but most authori- 
ties agree that the pressure exerted by the enlarged gland causes 
tracheal stenosis and secondary laryngeal spasm. In some cases 
which have presented no clinical evidence of stenosis of the trachea 
or spasm of the larynx, death is presumed to have resulted from cardiac 
paralysis, since there is also pressure upon the heart, great vessels, 
and vagi and recurrent nerves. Pressure upon the great vessels is 
held responsible for the general edema usually present in these cases, 
and pulmonary edema which frequently precedes death may be due to 
pressure on the pulmonary arteries and veins. Death from enlarged 
thymus is sudden, and a previously healthy child may be found dead 
in bed. Frequently death follows some trivial accident or occurrence, 
such as fright, or a fall into water, a slight burn, the prick of a hypo- 
dermic needle, or the inhalation of a few drops of an anesthetic. 
Trivial operations, such as the extraction of a tooth or removal of the 
tonsils and adenoids, have been fatal. Thymic death may occur 
during an acute infection, and is particularly frequent in diphtheria. 

STATUS LYMPHATICUS. 

Status lymphaticus is a rare condition in which there is found an 
enlarged thymus and general hypertrophy of the lymphatic system. 
The tonsils and adenoids are enlarged, and there is a hyperplasia of 
both superficial and deep lymph nodes. There is a tendency to hyper- 
plasia of the vascular system, seen especially in the aorta. From a 
clinical standpoint there is a lowered vitality, and an unstable equi- 
librium of vital forces which results in sudden death of the individual 
from cardiac and respiratory failure, brought on by trivial incidents. 

Symptoms. — The child may be apparently well, but looks anemic, 
and frequently shows signs of rachitis. It is subject to frequent 
attacks of tonsillitis and catarrhal conditions of the nose and throat. 
Gastro-intestinal disturbances are common. Cyanosis, dizziness, and 
syncope indicate an unstable circulation. A prominence of the upper 
part of the sternum and the suprasternal notch may be visible on 
inspection. The upper part of the gland may be palpable at the root 
of the neck, and the superficial lymph glands and spleen are found to 
be enlarged on palpation. Thymic dulness is increased as is shown 
by a wider area of impaired resonance on both sides of the upper part 
of the sternum. The stridor is frequently audible some distance from 
the patient, and is always heard distinctly all over the chest. 

Diagnosis. — The diagnosis of enlarged thymus is based upon the 
occurrence of chronic stridor, usually congenital, which at times 
becomes severe, resembling asthma, and may require intubation or 
tracheotomy for the relief of dyspnea. Careful examination of the 
throat should be made to exclude adenoids or malformations or 
obstruction of the larynx as a cause of the stridor. Enlarged bronchial 
glands may produce stridor by compression, but the enlargement 



508 DISEASES OF THE DUCTLESS GLANDS 

usually follows pertussis or bronchopneumonia, while thymic stridor 
is apt to be congenital. The £-ray is probably the most valuable aid 
in diagnosis of enlarged thymus, although variation in size, within 
reasonable limits, may be expected under normal conditions. 

Prognosis. — The prognosis of thymic enlargement is unfavorable. 
Recovery is quite, common in those cases with mild stridor, but when 
more severe symptoms develop, a fatal outcome is to be expected. 
Intubation or operations on the thymus are often successful in relief 
of symptoms, or as curative measures, but are very dangerous pro- 
cedures, since death frequently occurs during the administration of an 
anesthetic or on the operating table. Intercurrent infections are often 
fatal in a child with an enlarged thymus. 

Treatment. — The child with an enlarged thymus should live as quiet 
a life as possible, and be carefully guarded from all excitement. The 
general health must be improved by careful hygiene, outdoor life, 
and well-regulated diet. Bathing should be carried out most carefully 
and always in lukewarm water, as either extreme of temperature may be 
fatal. Acute infections of the upper respiratory tract are especially 
liable to precipitate an attack of thymic asthma, and should be care- 
fully avoided. During an acute attack of stridor or asthma hot or cold 
applications may be made to the neck or sternum. Cardiac stimulants 
with oxygen may be necessary to prevent suffocation. If dyspnea 
is severe, intubation or tracheotomy may be necessary. The parents 
should be told of the possibility of sudden death before anesthetization, 
which should be proceeded with most cautiously. Tracheotomy may 
be done under local anesthesia, and chloroform given through the 
tracheal cannula is preferred for thymectomy. Intubation may termin- 
ate a severe attack of thymic asthma, but if there be a stenosis of the 
trachea, the withdrawal of the tube causes another attack. The 
Roentgen ray brings about a decrease in size of the thymus, lymph 
nodes, and spleen when applied to the thymus in status lymphaticus, 
and the results are so satisfactory that this plan of treatment should 
always be tried. In children Roentgen irradiation is preferred to 
thymectomy because of the effect of removal of the thymus on the 
bones and sexual organs. For this reason partial thymectomy is the 
usual operation, or the organ may be stitched to the under surface 
of the sternum. 



DISEASES OF THE THYROID GLAND. 

GOITRE. 

Acquired goitre occurs most frequently in children at or before 
puberty, while congenital goitre is very rare and is only seen in 
goitrous districts where the parents are also goitrous. The infectious 



GOITRE 509 

diseases are occasionally followed by goitre. Exophthalmic goitre is 
rare in childhood, but may occur in the first year. 

Exophthalmic Goitre (Graves's Disease). — This disease, which was 
first described by Graves in 1835, is characterized by enlargement 
of the thyroid gland, tachycardia, exophthalmos, and muscular tremors. 

Etiology. — Emotional shocks, such as fright, grief, worry, are said 
to be important factors in the production of Graves's disease. During 
childhood it is most apt to occur in neurotic girls, at or about puberty. 
Infection can only be indirectly associated with exophthalmic goitre. 
The children of epileptic and alcoholic parents are said to be pre- 
disposed to this disease. It is more than twice as frequent in girls as 
in boys, but care must be taken not to confuse the hyperemic goitre 
which occurs in young girls with exophthalmic goitre. The hyperemic 
goitre is not accompanied by exophthalmos or tremors, and the con- 
dition disappears with menstruation. 

Symptoms. — The symptoms of exophthalmic goitre in the child 
are practically the same as in the adult. There is enlargement of the 
thyroid gland, tachycardia, exophthalmos, and muscular tremors. 
The symptoms may resemble chorea. The child is irritable, easily 
excited, and becomes depressed if left alone. There may be nausea 
and vomiting at the sight of food. In early childhood there is usually 
profuse diarrhea. The general health of the child is poor, sleep is 
disturbed, and there may be attacks several times a day in which there 
is a breaking out into cold perspiration. The skin may be pigmented. 
The eyes are staring and may bulge out of the orbital cavity so that 
there may be hesitation in the descent of the upper lid when the eyes 
are turned down. The enlargement of the thyroid is usually bilateral. 
There is a systolic murmur at the base of the heart, the blood-pressure 
is increased, and hemorrhages may arise from the nose, stomach, or 
intestines. 

Prognosis. — Graves's disease is rarely fatal in children but tends to 
run a chronic course with remissions of symptoms. The younger the 
child, the better the prognosis, as a rule. 

Treatment. — The patient should be put to bed and kept there until 
the active symptoms subside. The diet should be nutritious, but light, 
in order to avoid gastro-intestinal disturbances. The tachycardia 
may be so severe as to demand attention, and for this the child may be 
given spartein sulphate, strophanthus or digitalis. Cold applications 
to the heart are also beneficial. Belladonna combined with sodium 
iodide is beneficial in some cases. In conjunction with this treatment, 
the .r-rays, galvanic current, and injection of serum are sometimes 
used. Thyroidectin, a product from thyroidectomized sheep', has 
proven of distinct value in many cases and should be administered. 
The use of thyroid extract or the gland substance is contraindicated. 
Adrenalin extract and thymus gland have been used. When medical 
treatment fails, the case should be treated surgically, a partial thy- 
roidectomy being the usual operative procedure. 



510 DISEASES OF THE DUCTLESS GLANDS 



CRETINISM. 

Cretinism is a f or,m of idiocy associated with myxedematous cachexia 
and defective growth of the bony skeleton, and is due to deficient 
secretion of the thyroid gland. There are two forms, the sporadic and 
endemic, but the latter type does not occur in the United States. 

Etiology. — The endemic form of cretinism is seen in many of the 
geographical locations of endemic goitre. It is common in the goitrous 
districts of Europe, and particularly in Styria, the Tyrol, Savoy, 
Piedmont, and in Switzerland, but does not exist in those areas of 
North America where goitre is of frequent occurrence. Cretins in goitre 
districts have goitrous mothers, or both parents may be mild cretins, 
but cretins, as a rule, cannot conceive or bear a living child. The 
thyroid gland usually presents a goitre, and shows extensive degenera- 
tion in this form of cretinism, but the symptoms are practically the 
same as in the sporadic type. Sporadic cretinism is related to endemic 
cretinism, but the etiology and pathology differ. The parents of 
sporadic cretins are not goitrous, as a rule, but tuberculosis, alcoholism, 
and consanguinity in the parents are said to have a predisposing 
influence. Psychical disturbances in the mother during pregnancy, 
such as grief, worry, and fright have been noted in connection with 
cretinism. Thyroiditis, arising from trauma or during measles, 
enteritis, or typhoid fever may give rise to cretinism. It is rare in 
tropical climates, and extremely unusual in the negro. Male cretins 
are more common than females. 

Pathology. — The most important changes in the body of the cretin 
are related to the thyroid gland. The gland may be congenitally 
absent. In other cases it is goitrous, and in most cases it is atrophied. 
It may be so small as to be overlooked after careful search, and 
considered absent. The bony skeleton shows arrested and retarded 
development. The bones of the skull are thickened, the sutures remain 
open, and the fontanelles do not close until late. The base of the s^ull 
may be altered in shape, and the posterior clinoid processes are higher 
than the anterior. The foramina are narrowed. The bones of the 
extremities and the ribs may be altered in shape. The pelvis is narrow. 
Bony changes vary in degree according to the age at which the lack of 
thyroid secretion was felt. Adipose tissue is very abundant in the 
omentum, and also beneath the skin which is thick, with scanty 
development of hair and sweat glands. The brain shows no gross 
abnormality, but the pituitary is occasionally found to be atrophied or 
hypertrophied. 

Symptoms. — Evidences of cretinism are rarely noticed by the parents 
until after the first year. In those cases observed before the first year 
the infant is dull and passive, mentally inactive, and takes little or no 
interest in its surroundings, or as to how it is manipulated. It is 
usually of normal length and weight at birth, but fails to gain in height 
or weight. A child of eight years will simulate one of three, and full- 
grown cretins are never over three to five feet tall. The skin is thick, 



CRETINISM 



511 



coarse, and dry, but does not pit on pressure. The hair is dry and 
coarse and grows poorly. The fontanelles remain open late, but there 
are no signs of rachitis. The teeth may not appear, or if they do 
are late and very imperfect. The eyelids are wide apart. The 
nose is flattened, with the nostrils dilated, and the bridge sunken. 
The ears are large, and have a waxy appearance. The lips are thick, 
and the tongue which is thickened and broad, protrudes from the 
mouth. The neck is short and thick, and the head appears to be placed 
directly on the chest which is short and hollow. The abdomen is 
usually large, protuberant, and there is invariably an umbilical hernia. 
The arms and legs are short and stubby. The hands are spade-like, 




Fig. 48. — Cretinism. 



and the fingers are blunt. The genitals are large, and the skin of the 
scrotum is thick. Mental dulness may be noticed as early as the sixth 
month. The child has a vacant stare, a meaningless smile, and does 
not play. Deafness caused by adenoids or middle-ear disease, which 
is common in cretins, adds to the deficient mental state. Cretins 
may be trained just as animals are, and may even learn easy sen- 
tences, but further mental development is impossible. Both mental 
and physical exertions are difficult. The habits are uncleanly, and 
the disposition is usually pleasant, but may be vicious. The tem- 
perature is subnormal. The appetite is good but there is apt to be a 
dislike for meat. Constipation is usually met with, is obstinate, and 



512 



DISEASES OF THE DUCTLESS GLANDS 



may persist for a long time. Blood examination reveals an anemia 
with marked diminution in red cells and hemoglobin. The thyroid 
gland is not palpable. The arrest in mental and physical development 
varies according to the age at which the deficiency of thyroid secretion 
became effective. 

Diagnosis. — The diagnosis of a typical case, well advanced, is easily 
made, but early diagnosis, which is so extremely important, may be 
very difficult in infancy. The coarse, dry skin, short stubby extremities, 
subnormal temperature, and slow mental responses form a combina- 
tion which points strongly to cretinism. It must be differentiated 
from rachitis, Mongolian idiocy, achondroplasia, and dwarfism. 




Fig. 49. — A cretin, eighteen years old. 



Rickets. — The mentality in rickets is normal, and the characteristic 
bony changes are easily demonstrated by the skiagraph. 

Dwarfism. — Even if associated with idiocy, dwarfism may be 
differentiated by the absence of the facial expression of the cretin 
and the skin changes. The body of the dwarf shows symmetry, which 
the cretin lacks. 

Mongolian Idiocy. — Mongolian idiots present the characteristic 
slanting eyes, but lack the peculiar faces of the cretin. The body 
is more symmetrical, and instead of the apathy of the cretin undue 
restlessness is the rule. 



CRETINISM 



513 



Achrondroplasia. — This disease may be differentiated from cretinism 
by the fairly well-developed intelleet, and the more marked shortness 
of the extremities. The size of the thyroid gland may be of service in 
clearing up a puzzling case, and a trial administration of thyroid 
extract will show definitely whether cretinism be present or not. 

Prognosis. — The prognosis depends largely upon the stage of the 
disease at which treatment was instituted. The earlier it is given, the 
greater the improvement, but if the condition is neglected and allowed 
to continue too long the case may go beyond medical aid and fail to 
show even temporary improvement under treatment. When treat- 
ment is carried out thoroughly from an early stage of the disease, the 
improvement is miraculous. The child 
grows taller, gaining several inches each 
year. It loses its dull, apathetic appearance, 
and the mind becomes alert and receptive. 
Cretins rarely live over thirty years, although 
exceptional cases, attaining the age of fifty 
and sixty years, have been reported. Death 
is usually due to an intercurrent infection, to 
which they are very susceptible. 

Treatment. — The cretin must be treated 
for years if permanent results are to be 
obtained. The fact that the most beneficial 
results of treatment are noticed where it is 
instituted early in life, has already been 
emphasized. After treatment is once begun, 
a neglect of it causes a relapse and tendency 
toward the original condition. The ad- 
ministration of the desiccated extract of the 
thyroids of sheep is the accepted treatment 
for cretinism. The dose should commence 
with \ grain t. i. d. for an infant, and pro- 
portionately larger doses for children. The 
amount of thyroid taken daily should be in- 
creased until the maximum effect is obtained, 
and then kept at that level until the de- 
sired improvement has taken place. Recession of the tongue, loss of 
adipose tisue, change in the facial expression, and mental changes are 
the first signs of improvement. The skin becomes moist with restora- 
tion of activity in the sweat glands, the hair grows more abundantly, 
and is fine and glossy. The body becomes shapely, and there is a rapid 
increase in height. The mental improvement is even greater than the 
physical change. These results are usually obtained without increasing 
the dose over 15 to 30 grains daily, according to age. After definite 
improvement is noticed the dose may be gradually cut down, and even 
stopped at intervals, until the actual amount of thyroid required by 
the patient is ascertained. Grafting the thyroid glarid has not met 
with definite success, and the old method of feeding the fresh gland, 
33 




Fig. 50. — A cretin, twelve 
years old. 



514 DISEASES OF THE DUCTLESS GLANDS 

either cooked or uncooked, has been discarded. Overdoses of the 
thyroid extract may be quite serious, and too large doses cause head- 
ache, faintness, rapid pulse, nausea, and fever. Exaggerated pulse 
rate is an indication to cut down the dosage. In addition to the 
administration of thyroid extract, the child should have the benefit 
of the best hygienic measures. The diet should be carefully watched, 
and the protein intake increased. Fresh air is essential, and massage 
and exercise are of distinct value. 



DISEASES OF THE ADRENAL GLANDS. 

The adrenals rarely become diseased before the tenth year, but 
during early childhood may be the seat of hemorrhages or tumors. 
Hemorrhages into the adrenals may be capillary or punctate. They 
occur in the newborn, during the course of gastro-enteric infection, 
chronic cardiac or pulmonary disease, and in septicemia and pyemia. 
Some writers attempt to classify the symptoms into three groups: 
asthenic, nervous, and peritoneal. There is* usually associated with 
hemorrhage of the adrenals a severe acute illness and purpura. The 
onset is sudden, with fever, violent pain in the hypochondrium, 
convulsions, vomiting, diarrhea, tympanites, collapse and death in 
forty-eight hours. The symptoms, together with the purpura, simulate 
a fulminating type of one of the exanthemata, and unvaccinated cases 
are not infrequently mistaken for smallpox. The pathology is unknown, 
and the treatment ineffectual, because of the rapid progress and 
peculiar nature of the affection. 

Tumors of the adrenals, arising during childhood, may cause marked 
disturbances in development with regard to growth, and sexual develop- 
ment particularly. In some cases the symptoms are thought to be due 
to hypersecretion, and in other cases to toxic products from a breaking- 
down process in the tumors. It occurs much more frequently in girls 
than in boys, and if the girl be very young she tends to acquire the 
male sex characteristics. The reverse is not true in boys, but their 
development is also precocious. There is a marked tendency to take 
on fat, and an excessive growth of body hair. The outlook in these 
cases is unfavorable, for diagnosis is difficult, the growth rapid, and 
metastasis early and frequent. 

ADDISON'S DISEASE. 

Addison's disease is rare in children, and when it does occur usually 
comes on after the tenth year. It is characterized by pigmentation, 
muscular and vascular weakness, and nervous and gastro-intestinal 
disturbances. 






ADDISON'S DISEASE 515 

Etiology. — The exciting cause and predisposing factors of Addison's 
disease are unknown. 

Pathology. — In the majority of cases there is a lesion of the adrenals 
which show T s caseation and calcification. Tuberculosis also may be 
demonstrated in other parts of the body. The tubercle bacilli may 
be present in the adrenals at death. Some few cases are not tuberculous 
and the gland may show simple atrophy, resulting from a chronic 
interstitial inflammation. Sarcoma, cancer, and hypernephroma of the 
adrenals have also been found associated with Addison's disease. 

Symptoms. — The skin is pigmented and becomes a deep yellow or 
bronze; the discoloration beginning at the nipples, axillary regions, 
hands and face. The mucous membranes of the mouth and vagina 
are also pigmented. White areas of skin may be observed scattered 
over the body. Pigmentation of the mucous membranes is said to be 
pathognomonic of Addison's disease. The child very gradually becomes 
weak and emaciated and listless. This weakness progresses steadily 
to exhaustion, and the emaciation grows worse, with a rapidly develop- 
ing secondary anemia. There are vomiting, diarrhea, and other gastro- 
intestinal disturbances. Nervous symptoms are marked, and con- 
vulsions may occur. The heart is weak, and dyspnea and palpitation 
follow the slightest exertion. There may be abdominal pain, with 
rigidity of the walls of the abdomen, suggesting peritonitis. 

Diagnosis. — Although Addison's disease is rarely seen, the diagnosis 
may be made easily if there is pigmentation with gradual asthenia, 
uncontrollable diarrhea, vomiting, and abdominal pain. The pig- 
mentation must be differentiated from that caused by metallic poisons, 
such as silver, lead, and arsenic. Other symptoms of Addison's 
disease may suggest a primary anemia, but this may be excluded by 
careful study of the blood. Tuberculosis of the peritoneum., with 
melanodermic and abdominal crisis may resemble Addison's disease, 
but there is no pigmentation of the mucous membranes in tuberculous 
peritonitis. 

Prognosis. — The course of the disease is much more rapid, and 
death comes on sooner in children than in adults. Practically every 
case is fatal, and doubt exists as to the true nature of the disease in 
those cases with recoveries reported, although recovery is possible. 
If there is uncomplicated tuberculosis of the gland, the disease runs a 
slow course and may last years, but cases due to atrophy of the adrenals 
are rapidly fatal. Death may come on gradually from exhaustion, 
or suddenly with diarrhea, vomiting, fever, syncope, toxic symptoms, 
and paralysis of the cardiac muscles. 

Treatment. — The treatment of Addison's disease is largely symptom- 
atic. The child should have plenty of rest, a light nutritious diet, 
and be kept warm at all times. Tonics containing arsenic or strychnine 
may be given. Hematinics and roborants are sometimes used. 
Glandular extracts from the parathyroids, pituitary, and suprarenals 
have been tried in these cases with indifferent success. The adrenal 
gland of the sheep may be given raw or cooked; the dose varies up to 



516 DISEASES OF THE DUCTLESS GLANDS 



one-half gland, according to the age of the child. The dose of the 
dried gland in tablet form is from J to J grain t. i. d. There have 
been cases reported where adults were benefited by operative treat- 
ment, and this may, at times, be advisable in the child. 



THE PINEAL GLAND. 

The pineal body which lies under the posterior end of the corpus 
callosum is occasionally during childhood the site of tumors which 
cause characteristic changes in development. The growth of the 
child is markedly increased and there is psychic as well as physical 
precocity. The sexual organs grow very rapidly and functionate 
early. In boys, especially, there is early and profuse growth of the 
beard and body hair. The child is obese, the voice changes early and 
cachexia gradually develops. As in tumors of the pituitary gland, 
the progress varies according to whether the tumor be malignant or 
benign. In either case the prognosis is fatal, and treatment, at the 
best, will only bring temporary relief of symptoms. 



THE PITUITARY GLAND. 

The pituitary body is sometimes during childhood the site of 
both benign and malignant tumors, which, in addition to the usual 
symptoms of cerebral tumor, also cause precocious development. 
There is a marked increase in adipose tissue and a lack of sexual 
development, the diminutive size of the organs being made more 
striking by the oversized child. The penis may be infantile after the 
age of puberty. Symptoms of cerebral tumor are usually present, and 
include headache, vertigo, vomiting, somnolence, and epilepsy, with 
disorders of the taste, smell, and vision. The course depends upon the 
character of the growth, and is rapid if there be malignancy, but may 
be very gradual, with remissions, if the tumor is benign. The treat- 
ment is surgical if the symptoms become severe, but the ultimate 
result is fatal. The headache is often severe and hard to relieve. 
Pituitary extract has been used upon the basis of hyposecretion, 
and thyroid extract is sometimes given for the adiposity. 



CHAPTER XVIII. 
DISEASES OF THE BONES AND JOINTS. 

ACUTE INFECTIOUS OSTEOMYELITIS. 

Definition. — Acute infectious osteomyelitis is most common during 
childhood and signifies an acute infectious inflammation of the bones. 

Etiology. — The infection is hematogenous, the organisms gaining 
access to the blood through ulceration of the mucous membranes, 
lesions of the skin, and intestines. The Staphylococcus pyogenes 
aureus is the invading organism, in most cases, but the Bacillus influenzae, 
Bacillus coli, and Bacillus typhosus have also been isolated. Strepto- 
cocci may be found in cultures from cases following scarlet fever, 
measles, or pneumonia. The pneumococcus has been isolated in a 
few cases, and may complicate or occur independently of pneumonia. 
Injury to a bone predisposes to an acute osteomyelitis, and compound 
fractures are a common cause. This disease occurs with equal frequency 
x in boys and girls. 

Pathology. — The infection may begin as a periostitis and extend 
into the marrow cavity through the Haversian canals or juxta-epiphy- 
seal disks, or it may arise in the marrow cavity and infiltrate the 
cancellous bone, giving rise to necrosis with a periostitis following. 
After the deposition of the infecting organism in the tissues, there 
follows hyperemia, swelling, and rapid formation of pus which may 
fill the medullary cavity. The pus may infiltrate the epiphysis and the 
joint may become involved, or it may, after involving the periosteum, 
rupture through and burrow along the line of least resistance to the 
skin. 

As a rule the infection spreads rapidly, but it may become circum- 
scribed in a bone, forming a bone abscess. The long bones are most 
frequently involved, but acute osteomyelitis has been observed in 
the bones of the hands, feet, and skull. 

Symptoms. — The onset is sudden in children. There is high fever, 
preceded by a chill and accompanied frequently by vomiting. Pain 
is acute and severe, and there is exquisite tenderness in the affected 
part. This may be hard to demonstrate in very young children, but 
the part soon becomes red and swollen, with an increase in the local 
temperature. Bacteria may be found in the blood stream. 

Diagnosis. — The diagnosis is not usually attended with difficulty 
and is made on the acute onset, with localized symptoms usually 
referable to one of the long bones, and accompanied by severe con- 
stitutional disturbances. 

Prognosis. — The prognosis is serious in very young children, and the 
mortality is over 50 per cent. This is caused by the development of 



518 



DISEASES OF THE BONES AND JOINTS 



secondary foci of suppuration. In older children the outlook is much 
better, and recovery may be expected in over 80 per cent, of cases. 

Treatment. — The treatment of acute infectious osteomyelitis is 
surgical. 

TUBERCULOSIS OF BONES. 

Bone tuberculosis may, as a part of miliary tuberculosis, give rise 
to an acute tuberculous osteomyelitis, but the chronic form of bone 
tuberculosis is by far the most common type. The bacilli are carried 
to the bone through the blood stream, and may set up a destructive 
inflammatory process in any part of the bone, but the infection usually 




Fig. 51. — Tuberculosis of foot. 



begins in the epiphysis. The process shows a tendency to extend, 
and, as a result, the neighboring joint and surrounding tissues become 
involved, with the formation of a "cold abscess/' 

Bone tuberculosis is usually secondary to some foci in the body. 
The human type of tubercle bacillus is practically always present. 
During the first three months of life, tuberculosis of bone is rare. The 
most frequent sites are the neighborhood of joints of the vertebrae 
and the long bones, while the bones of the hands and fingers are very 
rarely involved. 

Symptoms. — Pain is constant in bone tuberculosis, but is often 
indefinite and obscure. It is rarely present in the onset, and when 



SYPHILIS OF BOXES 519 

present is almost invariably referred to some other part. The sur- 
rounding tissues are gradually involved, causing swelling of the part 
and frequently, suppuration. The general health is impaired, and 
emaciation and cachexia develop in the later stages. 

Diagnosis. — The question as to whether a bone lesion is syphilitic 
or tuberculous will arise in a great many cases. If tuberculous the 
pain is less severe, suppuration is more frequent, and the tissues 
surrounding the infected bone are involved. Other foci of tuberculosis 
may sometimes be found, and a tuberculin test should be made. The 
constitutional symptoms are more marked in tuberculosis of the bones. 
In acute inflammation the process is always rapid, while tuberculosis 
is slow. 

Prognosis. — The prognosis is good if the case is treated early and upon 
rational principles that have been proven efficacious in lung tuberculosis. 

Treatment. — The treatment of bone tuberculosis is both general 
and local. Outdoor life at the seashore where the climate is equable 
is ideal for these children. The diet should consist largely of milk, 
eggs, oatmeal, and other high protein cereals. Tonics, such as cod- 
liver oil, malt, tincture of nux vomica, iron, and quinine are indicated 
if they do not interfere with digestion and the appetite. 

Local treatment consists in extreme conservation, which is more 
successful in children than in adults, probably because the after- 
treatment is carried out to a greater degree. Avoidance and, later, 
correction of deformity are aimed at, and strict immobilization is 
maintained in the most favorable position by means of carefully 
applied plaster-of -Paris splints. 

Abscesses should rarely be opened, as they always become absorbed 
when the patient's general health has received proper attention. 
Injection treatment in bone tuberculosis is useless. The evacuation 
of a tuberculous abscess always tends toward a perpetual sinus, with 
accompanying mixed infection. 

SYPHILIS OF BONES. 

The bone changes in delayed hereditary syphilis usually come 
on at about the fifth year. The long bones are most frequently 
involved, particularly the tibia. The greatest changes are seen at or 
near the epiphysis, causing an irregular broadening of the epiphyseal 
line. There are proliferative changes in the periosteum from a chronic 
or subacute periostitis, and this may often be detected by running 
the finger down along the crest of the tibia. The epiphyseal junction 
is enlarged and swollen, and in exceptional cases the epiphysis may 
become detached. Gummata are infrequent in bones. 

Symptoms. — Swelling and enlargement of the epiphysis, with 
roughening along the shafts of the long bones, is characteristic of 
syphilis. Pain is acute and worse at night. Suppuration rarely occurs 
as a result of bone syphilis, and there is no cachexia or other marked 
constitutional symptom. 



520 



DISEASES OF THE BONES AND JOINTS 



Diagnosis. — Bone syphilis must be differentiated from tuberculosis 
of the bones, and from rachitis. In addition to the points of differen- 
tiation from tuberculosis, mentioned in the diagnosis of bone tuber- 
culosis, a positive Wassermann reaction and the concomitant signs of 
syphilis may be present. In rachitis the bones are not so painful as in 
syphilis, and there is no roughening, although they, may be thickened 
at the ends. 

Prognosis. — The prognosis is good if the child comes under obser- 
vation early, and treatment is carried out thoroughly. 

Treatment. — Syphilitic bone lesions in children respond strikingly 
to mercury and the iodides. A child five years of age should be given 
from -gjf to 2V °f a grain of bichloride of mercury daily, with from 12 to 
20 grains of potassium iodide daily, the drugs being given in separate 
mixtures. If the bichloride of mercury given by the stomach disagrees, 
from 20 to 30 grains of mercurial ointment may be well rubbed into 
the skin daily. In order to prevent gastric disturbance, the adminis- 
tration of potassium iodide should be interrupted for a few days 
every month; later these drugs may be given alternately. The part 
should be protected locally, and placed at rest. Suppuration calls 
for surgical intervention with removal of the dead bones.' 




Fig. 52. — Tuberculous dactylitis of ring finger. 



DACTYLITIS. 

Dactylitis is a disease of the phalanges in children, causing a fusiform 
swelling, and may be syphilitic or, rarely, tuberculous. It may also 
be due to streptococcic infection or trauma. 

Pathology. — In both tuberculous and syphilitic forms the process, 
which is a rarefying osteomyelitis, begins in the centre of the bone, 



CRANIOTABES 521 

resulting in an enlargement of the medullary canal, while at the same 
time there is a proliferative periostitis, causing a fusiform enlargement. 
Suppuration and necrosis occur, and a finger or toe may be lost. 
An acute dactylitis, arising from streptococcic infection or trauma, 
presents the symptoms of acute osteomyelitis. 

Diagnosis. — Syphilitic dactylitis is more common than the tuber- 
culous form. It occurs most frequently during the first two years and 
usually involves several bones. The proximal phalanges are apt to be 
involved in syphilis, and there is not the tendency to affect the meta- 
carpals, seen in tuberculosis. There is rarely suppuration, and the 
surrounding tissues are usually not involved if the type be syphilitic. 

In the tuberculous form metacarpals and phalanges are involved. 
There is tumefaction, due mostly to swelling of the soft tissues, and the 




Fig. 53. — Syphilitic dactylitis involving all fingers and thumb of left hand 
and thumb of right hand. 

part is tender. The tuberculous lesions are less apt to be multiple. 
The history of the case, the presence of concomitant symptoms of either 
disease, and the Wassermann and von Pirquet tests are additional 
aids to diagnosis. 

Prognosis. — The underlying constitutional disease should be treated 
at once. Locally the part should be put at rest and kept immobile 
by splints for months. Abscess formation and necrosis, if they occur,, 
require surgical intervention. 

CRANIOTABES. 

Craniotabes is a condition characterized by the presence of soft 
spots of thinning in the cranial bones. It may be due to several causes. 
Syphilis is found in over 50 per cent, of the cases. Rachitis is also 



522 DISEASES OF THE BONES AND JOINTS 

present quite frequently, and the most marked cases are seen in chil- 
dren with both syphilis and rachitis. It may occur in hydrocephalus 
of the chronic type. 

In a certain percentage of the cases, no underlying condition can 
be found to account for the craniotabes. These areas are found in the 
parietal and occipital bones. They are caused by bony absorption 
which begins on the inner table of the skull, and is supposed to be due 
to pressure of the brain internally, and the pillow externally. 

BOSSING OF THE SKULL. 

Bosses on the bones of the vault of the skull are caused most fre- 
quently by rachitis or syphilis. The most marked cases are seen in 
children where both these etiological factors are present. This con- 
dition is due to exuberant formation of bone around the centres of 
ossification. 

Bosses are usually found on the frontal and parietal bones, but may 
occur in the occipital and temporal regions. They may be confused 
with the osteoperiostitis of the bones of the skull seen in tuberculosis. 
Among the rarer causes of bossing are achondroplasia, hereditary 
cleidocranial dystosis and tumors. 

ACUTE ARTHRITIS OF INFANTS. 

This disease is also known as acute purulent synovitis and acute 
epiphysitis. It is a form of pyemia resulting in an acute inflammation 
of the joints with suppuration. The majority of cases occur during the 
first year, and most of these are seen during the first six months of life. 
The disease may begin in the epiphysis or medullary canal, but the 
joint is soon involved, the nature of the arthritis depending upon the 
infecting organism. The gonococcus causes an inflammation of the 
joint proper, and the synovial membrane is involved, but there are no 
destructive changes in the cartilage, ligaments, or bone. 

The cases due to the staphylococcus or streptococcus are more 
severe, and the joint may be destroyed. The suppurative process 
shows a tendency to spread, and may result in diffuse osteomyelitis, 
subperiosteal abscess, or even a separation of the epiphysis. The 
final outcome is either a flail joint or bony ankylosis. 

Etiology. — The infection is hematogenous, and may occur very 
soon after birth from an infected umbilicus. During the later months 
of infancy the organisms may enter the blood stream through abrasions 
of the skin or from the conjunctiva, genital tract or mouth. In some 
cases the portal of entrance cannot be demonstrated. The staphylo- 
coccus, streptococcus, gonococcus, and pneumococcus have been 
isolated. 

Symptoms. — The constitutional symptoms are marked, and usually 
precede local signs. There is high fever, malaise, anorexia, and 
vomiting. Following this, one or several joints become swollen, 



TUBERCULOSIS OF JOISTS 523 

painful and tender. The overlying skin is reddened, and the local 
temperature increased. Suppuration occurs rapidly, and fluctuation 
may be present. 

In severe cases, a general pyemia may develop, with visceral com- 
plications, such as pneumonia, pericarditis, or meningitis. In milder 
cases, the abscesses continue to grow larger and suppuration is con- 
fined to the joints. In the gonococcic form there may be no suppu- 
ration. 

Diagnosis. — Some cases resemble acute rheumatic fever, but there 
is no endocarditis, and the joint lesions are much more severe. Syphil- 
itic and tuberculous epiphysitis are very much more chronic in nature, 
the symptoms are not as severe, and other evidences of these diseases 
are present. 

Treatment. — Cold compresses should be applied locally for relief 
of pain. When fluctuation is apparent, free evacuation of the pus 
should be obtained by an incision into the joint cavity. This should be 
followed by fixation of the joint. Life is often saved by prompt 
evacuation of pus, but the function of the joint is usually impaired. 

TUBERCULOSIS OF JOINTS. 

Tuberculosis is the most frequent infection of joints during childhood, 
and is usually secondary to tuberculosis of the epiphysis. In some cases 
there may be no demonstrable foci of tuberculosis anywhere else in 
the body. The process is essentially chronic, but an acute tuberculous 
osteomyelitis may sometimes be observed in miliary tuberculosis. 

Symptoms. — The onset is insidious, and the earliest symptoms may 
not be noticeable to the parent. Pain is indefinite, quite obscure, 
intermittent, and referred to more or less remote parts. Impairment of 
function and atrophy of the muscles connected with the joint together 
with characteristic night cries are among the earlier symptoms. The 
joint may become swollen, and there is tenderness on pressure. 

Spasm of the muscles surrounding an affected joint is one of the most 
constant symptoms. Eigidity is not present until the later stages of 
the disease, and fluctuation cannot be detected until the destructive 
process is well advanced. The constitutional symptoms are night 
sweats, night cries, anemia, anorexia, and a slight afternoon tem- 
perature. 

Diagnosis. — Intermittency of symptoms often causes delay in arriv- 
ing at a correct diagnosis. The chronic nature of a tuberculous 
arthritis distinguishes it from acute inflammatory rheumatism and 
acute infectious arthritis. Syphilitic arthritis is very rare, and is usu- 
ally manifested by a bilateral effusion of the knee-joints. It responds 
quickly to the mercurials and iodides, so that the therapeutic test is of 
value in the differentiation. In syphilis the Wassermann reaction 
will be found positive, and concomitant signs may be in evidence. A 
positive von Pirquet reaction, and the presence of other foci of 
tuberculosis mav be demonstrated in tuberculous arthritis. 



524 DISEASES OF THE BONES AND JOINTS 

Prognosis. — The prognosis is good if treatment is instituted early, 
and the destructive process stopped; otherwise, the condition grows 
steadily worse, and complete disorganization of the joint may result. 
Complete recovery with little or no impairment of motion is often 
obtained under careful management. 

Treatment. — The treatment of uncomplicated cases of joint tuber- 
culosis is conservative. This conservative treatment of bone tuber- 
culosis in the child is extremely important. The tuberculous process 
in children almost invariably begins in the epiphysis or the juxta- 
epiphyseal region. Active operative interference on the epiphysis 
interferes with the subsequent growth in the length of the bone, which 
is a matter of vital importance. 

Local pain, swelling, effusion into the joint, and fever do not 
necessarily point to operative interference unless pyogenic bacteria 
are present, with a resulting formation of pus. Of course, if pyogenic 
pus — not tuberculous pus — is present, an opening must be made and 
the pus removed. 

Absolute rest to the joint, life in the open air, good food, and appro- 
priate tonics, with plenty of time, will accomplish a great deal in 
children. This element of time is less important in the child than 
in the adult; usually the adult is a wage-earner, and the loss of time 
is a more serious matter. The joint should be put at rest in a plaster- 
of -Paris cast, but weight bearing has been proven not to be injurious 
when proper fixation of the joint is secured. Passive hyperemia, if 
used carefully and systematically, is of benefit in the earlier stages of 
the disease. Tuberculin is often administered with good results. 

In the later stages, when the joint becomes destroyed and systemic 
symptoms are marked, arthrectomy may be considered but is rarely 
advisable. Cold abscesses are complications in about 50 per cent, of the 
cases of tuberculous arthritis, and when they occur they should not 
be opened except when spontaneous rupture is inevitable. The child 
with a tuberculous lesion in a joint should be put under the most 
hygienic living conditions, and everything possible should be done to 
improve the general health. Life at the seashore is of special benefit 
to these children. 



CHAPTER XIX. 
DISEASES OF THE GENITO-URINARY SYSTEM. 



DISEASES OF THE KIDNEY. 

THE URINE. 

The infant usually micturates within twelve hours after birth, 
and in many cases micturition occurs spontaneously with birth. 
Certain constituents of urine are found in the liquor amnii, indicating 
intra-uterine activity of the kidneys, if not actual urination. The 
bladder normally contains urine at birth. The amount of urine passed 
daily and the specific gravity and percentage of the different constit- 
uents vary greatly during infancy, as well as during the greater part 
of childhood. 

Quantity. — The quantity of urine passed for the first three days 
corresponds to the amount of liquids ingested. At each evacuation 
of the bladder from J to J of an ounce is passed, with a total quantity 
of from 2 to 3 ounces in twenty-four hours. With the establishment 
of breast-feeding, the amount of urine increases with each succeeding 
day, and at the end of the first week the dailv output is about 8 
ounces. At six months, the average daily quantity of urine passed is 
about 12 ounces, and at two years 16 ounces. From the second year 
onward the daily output of urine increases 1^ ounces each year until 
the child is twelve years of age. There is an increased quantity of 
urine in diabetes mellitus and chronic interstitial nephritis, and a 
decrease in renal congestion and acute nephritis. 

Children pass relatively larger amounts of urine than adults. Nor- 
mally micturition occurs often during infancy, and a baby may urinate 
from ten to fifteen times a day under ordinary circumstances. There 
is great difficulty in collecting a twenty-four-hour specimen in children 
because of this frequency in urination, and the trouble experienced 
in securing a retainer to the child or infant. Male infants may have 
a condom attached to the penis, or a wide-mouthed bottle. Absorbent 
cotton may be used to collect the urine of female infants. These 
methods, however, all expose the specimen to contamination, and 
render it useless for bacteriological study, though perfectly reliable 
for ordinary chemical tests. To obtain an unadulterated specimen, 
a No. 6 American gauge catheter should be passed, and suprapubic 
pressure made, preferably after the child has been sleeping for a long 
time. 



526 DISEASES OF THE GEN I TO-URINARY SYSTEM 

Specific Gravity. — For the first twenty-four hours the specific gravity 
averages 1005 to 1010, for the child does not ingest much liquid. 
When nursing becomes regularly established, the specific gravity 
falls to 1003 or 1004, and remains at this level during breast-feeding. 
From the second year the specific gravity steadily increases, until 
at puberty it ranges from 1010 to 1015. The specific gravity is 
increased by diarrhea, fever, and sweating. 

Reaction. — The urine at birth is acid, and remains faintly acid, nor- 
mally, throughout life. The ingestion of an alkaline diet will change 
the reaction of the child's urine, and a diet containing too much fat 
may cause it to become ammoniacal. 

Color.— The color of the urine is a fair indication of its specific 
gravity, a pale yellow urine usually having a low specific gravity, and 
a high-colored urine, being concentrated, having a high specific 
gravity. The urine of infancy is much paler than during childhood. 
In fevers the urine becomes high-colored and turbid. Milky-white 
urine suggests pus, while urine of a reddish hue should lead one to 
suspect the presence of blood. Bile is sometimes found in the child's 
urine, and imparts to it a greenish-yellow color. 

Hematuria. — Hematuria is the term applied to urine that contains 
blood corpuscles and blood pigment. In every case of suspected hema- 
turia a microscopic study of the urine should be made to determine 
the presence of blood corpuscles, which differentiate this condition 
from hemoglobinuria. While the causes of hematuria are many and 
varied, idiopathic hematuria is quite common in children. These 
cases are unassociated with any appreciable constitutional disturb- 
ance, and no organic lesion can be demonstrated to account for the 
appearance of the blood. They usually clear up in a day or two, and 
are sometimes referred to as renal epistaxis. In some instances large 
quantities of blood may appear in the urine with no other symptoms 
than a slightly increased frequency of urination. The best treatment 
for these cases is rest in bed, mild catharsis, and a soft diet. 

Hematuria immediately following birth may be due to the passage 
of uric acid crystals and infarcts, to hemorrhagic disease of the new- 
born, or to septic infection. After infancy it is seen most frequently 
in scarlet fever, typhoid fever, malaria, variola, scurvy, purpura, hemo- 
philia, and leukemia. The ingestion of certain drugs, such as canthar- 
ides, turpentine, and other poisonous substances may also give rise 
to hematuria. Blood appearing in the urine may have come from the 
kidney, ureter, bladder, urethra, or from the genital tract. When 
hematuria has its origin in the kidney, urine is usually abnormal in 
color, the blood imparting to it a smoky hue. The appearance of blood 
casts in the urine is significant of renal hematuria. 

The most common causes of hemorrhage from the kidney are the 
acute infectious diseases, hyperemia of the kidney, and acute nephritis. 
It may occur during chronic nephritis, and is also seen in association 
with infarcts, tuberculosis of the kidney, neoplasms, calculi, parasites, 
angiomata, abscesses, embolism, and cysts. 



THE URINE 527 

Hemorrhage from the ureter is usually caused by the passage of a 
stone or by neoplasms. Blood which comes from a lesion of the bladder 
is usually normal in color, and sometimes very abundant. It is gen- 
erally due to either tuberculosis of the bladder, vesical calculi, or 
neoplasms. The blood from a hemorrhage of the urethra is normal, 
and may be uncontaminated with urine. It may be due to traumatism 
from stone or catheter, and in some cases is caused by gonorrhea. 
The treatment of hematuria consists, for the most part, in tracing 
the source of the hemorrhage, and removing its cause. Rest in bed, 
mild purgation, and a light diet are also beneficial. 

Hemoglobinuria. — Hemoglobinuria is that condition in which blood 
pigment only is found in the urine, no blood corpuscles being present. 
Hemoglobinuria indicates either that the blood cells are being destroyed 
by some process and hemoglobin is being set free in the circulation, 
or that the hemoglobin is being dissolved out of the blood cells and 
passes into the circulation. Hemoglobinuria in epidemic form occurs 
in the newborn, being known as YYinckel's disease. It may be pro- 
duced by the ingestion of poisons such as potassium chlorate or car- 
bolic acid. It is occasionally observed in the course of yellow fever, 
typhoid fever, malaria, and scarlatina, and occurs in children affected 
with scurvy, inherited syphilis, or purpura. 

There is a paroxysmal form of hemoglobinuria in which the cause 
is unknown. The attacks are accompanied by chills, dyspnea, pal- 
pitation, and cyanosis. It is thought that the individual carries the 
hemolysin in his own blood, but, in addition, cold and exertion are 
necessary to precipitate an attack. Syphilis is regarded as a factor 
in this type of hemoglobinuria, having been found associated in 50 
per cent, of the cases of the disease. 

The treatment of hemoglobinuria is to remove the cause and support 
the child's strength by plenty of rest and a good nourishing diet. 
Syphilis should be suspected in every case, and upon its discovery 
antisyphilitic measures at once instituted. 

Functional Albuminuria (Postural Albuminuria, Cyclic Albuminuria, 
Orthotic Albuminuria). — Functional albuminuria occurs principally 
in children, and is characterized by the presence of sero-albumm in 
the urine in the latter part of the forenoon and afternoon only. It 
disappears after a night's rest. The term "cyclic albuminuria" 
designates its regular appearance at certain hours of the day, and 
"postural albuminuria" that the erect posture on arising is a factor 
in its production. Albuminuria has been observed frequently in chil- 
dren with lordosis of the lumbar vertebra?, and is sometimes referred 
to as lordotic albuminuria. 

Symptoms. — Children who give evidence of functional albuminuria 
are usually neurasthenic, and have an anemic appearance. They 
complain of vague pains, headache, and sometimes nausea. There 
is a lack of tone in the involuntary muscles. Dilatation of the stomach 
and heart are common. The pulse tension is low; the hands frequently 
become cyanosed. Many of these little ones suffer from epis taxis. 



528 DISEASES OF THE GEN I TO-URINARY SYSTEM 

On the other hand, functional albuminuria may be observed in chil- 
dren apparently enjoying good health. 

Diagnosis. — A diagnosis of functional albuminuria should be made 
only after careful consideration and the exclusion of any signs con- 
firmative of pathological albuminuria. Its most distinguishing 
features are the entire absence of symptoms of nephritis and of casts 
in the urine, also the effects of rest on this condition. 

Treatment. — Recovery from functional albuminuria is often slow, 
but is the rule. It may be hastened by a change of residence to a 
healthful, invigorating climate, and careful regulation of the diet to 
increase nutrition. Strychnine sulphate, in tonic doses of 2 iro to y^ 
of a grain, taken twice daily, is of recognized value in this con- 
dition. 

Paroxysmal Albuminuria. — Paroxysmal albuminuria may be recog- 
nized as one of the forms of functional albuminuria. It is most fre- 
quently observed in connection with paroxysmal hemoglobinuria. 
There are no associated symptoms of nephritis during an attack, and 
the urine contains no casts. Between attacks, which usually last 
two or three days, the child enjoys good health. 

Lithuria. — An excess of uric acid bodies in the urine is termed 
lithuria. It is common in children from birth to puberty, and indi- 
cates an increased amount of uric acid in the blood and tissues. Since 
the deposition of amorphous sediments of urates as the urine cools 
is a common event, and, in view of the fact that such trivial causes 
as mere concentration of the urine, or an increased acidity, or the tem- 
perature of the air, may precipitate these uric acid bodies, the amount 
of the sediment must not be interpreted as indicative of the amount 
of uric acid output. 

Symptoms. — During infancy the urine contains a comparatively 
small amount of urea, but the uric acid output is high; in some cases 
the minute crystals coalesce and form calcareous masses. The passage 
of these masses and of uric acid infarcts may cause considerable abdom- 
inal colic, with tenderness over one kidney. The irritation produced 
by these bodies is evinced by the appearance of blood, of albumin, 
and even of casts in the urine. In infants there may be slight hemor- 
rhage, giving rise to actual hematuria for a week or so during the 
excretion of crystalline uric acid. 

A mild inflammation of any part or of the entire urinary tract is 
sometimes shown by the presence of large numbers of epithelial 
cells, leukocytes, and red blood corpuscles, also of mucus. After 
infancy an excess of urates in the urine is not so frequent; but in 
nervous, irritable, anemic children there may be recurrent attacks 
throughout childhood. It is sometimes observed in chorea, chronic 
dyspepsia, malnutrition, rheumatism, and scurvy, and always indicates 
severe nutritional disturbance. The microscopic features of the 
urinary sediment in lithuria. are large numbers of uric acid crystals 
and a moderate collection of calcium oxalate crystals. A simple test 
is the application of heat to a specimen of urine, whereupon the tur- 



THE URINE 529 

bidity will disappear and the sediment, if composed of uric acid or 
urates, will be dissolved. 

Treatment. — Regulation of the diet is impossible during infancy 
as the child should be kept on the breast; but older children may be 
placed on a diet that is poor in purin substances. Alkaline diuretics 
are indicated, and, to a child of three years, 5 grains of potassium 
bicarbonate, or 3 grains of potassium citrate, may be given four 
times a day to advantage. 

Acetonuria. —Acetone is found in minute quantities in normal urine, 
but may be considerably increased in many pathological conditions. 
In children acetonuria is induced by slight causes, of which changes 
in the diet are, perhaps, most common. The chief cause of the for- 
mation of acetone is, apparently, the withdrawal of carbohydrates 
from the food, or inability to utilize carbohydrates. That carbohy- 
drates alone are not the only factors in the production of acetonuria 
is demonstrated by the increased acetonuria caused by a diet rich in 
fats; and, in view of most recent experimental research, there seems 
to be no doubt that the proteins of the food and tissues must be 
looked upon as contributing to the total yield of acetone. 

The frequency of acetonuria in diabetics need not be emphasized; 
but it also occurs in malignancy, prolonged fevers, starvation, diges- 
tive disturbances (especially when associated with persistent vomit- 
ing), and is frequently associated with bronchopneumonia. The 
appearance of acetone in the urine of epileptics lias no bearing on the 
convulsive seizures, and though the association of acetonuria with 
cyclic vomiting is as yet not clearly understood, it is thought to be 
the result of the persistent vomiting, rather than the cause. 

Symptoms. — The most important symptoms of acetonemic acidosis 
are dyspnea, or air-hunger, rapid pulse, and in fatal cases coma. 
The diagnosis, however, is based on an examination of the urine which 
reveals the presence of acetone and, perhaps, its kindred bodies — 
diacetic acid and oxybutyric acid. The presence of acetone is indi- 
cated by the well-known iron reaction; i. c, the development of a 
deep red-brown color on the addition of a solution of ferric chloride 
to a specimen of urine. 

When patients are taking salicylates or aspirin this reaction is, of 
course, masked by the iron reaction due to the drug. If doubt exists 
as to the cause of the reaction, the urine should be boiled* for a few 
minutes, and the test repeated after it has cooled. As a result of such 
treatment acetoacetic acid will be broken up into acetone and carbon 
dioxide, and the reaction will no longer be obtained. 

Treatment. — The first thing to be done in a severe case of acetonuria 
combined with great acidosis is to give a purge of calomel, 2 grains to 
a child of three years, followed by a saline cathartic; magnesium sul- 
phate, 1 dram every two hours until free catharsis is produced, would, 
perhaps, be better. In addition to this, two measures are clearly 
indicated — the administration of alkalies to neutralize the acidosis 
and the giving of easily assimilable carbohydrates, such as levulose 
34 



530 DISEASES OF THE GEN I TO-URINARY SYSTEM 

or glucose. Sodium bicarbonate is probably the most efficient alkali, 
and should be given in 30-grain doses with glucose by the mouth, 
unless there be persistent vomiting, when both of these drugs may be 
given in solution by rectum. Fresh air, outdoor exercise, and massage 
are all beneficial, and prophylactic measures to promote convalescence. 

Indicanuria. — Indican is found in minute quantities in the normal 
urine when a mixed diet is being ingested, and may be much increased 
by a protein diet, since it is derived from the proteins of the food 
which are in part decomposed in the intestine by bacteria. It may 
also be produced by conditions in which the cavities of the body con- 
tain fetid pus, as in fetid empyema and pulmonary abscess. With 
this exception, indicanuria may be considered a sign of bacterial 
disintegration of proteins in the intestinal canal, and the amount of 
indican in the urine as an index of the extent of this putrefaction. 

Although indicanuria is, in most cases, due to either acute or chronic 
intestinal derangement, it is also frequently observed in chorea, typhoid 
fever, peritonitis, epilepsy, and malignancy. It is especially common 
in tuberculous enteritis, and has also been found in association with 
urticaria and other skin diseases. Indican is usually absent in the 
urine of normal breast-fed babies, but appears soon after infancy; it 
is much increased by constipation or masturbation, so that a strong 
indican reaction in children is always of pathological significance. 

In testing for indican it is essential that a freshly voided specimen 
of urine be used, as indican rapidly disappears on standing, and 
renders an accurate estimate of the quantity of indican impossible. 
If tested accurately, the quantity of indican may serve as a guide to 
the severity of the associated disease and the effects of treatment. 
The presence of indican is detected by adding to 10 c.c. of normal 
urine an equal volume of hydrochloric acid and 1 or 2 drops of liquor 
sodse chlorinatse, or 3 drops of aqua hydrogenii dioxide, or a small 
pinch of sodium perborate. On standing several hours, the color 
changes to a bluish hue from the formation of indigo blue. By shak- 
ing with 1 c.c. of chloroform, the indigo dissolves and settles as a 
blue bottom layer, when the amount of indican may be estimated by 
the depth of the color. 

Treatment. — The indications for treatment are to control the 
putrefactive process going on in the intestinal tract by the same 
measures referred to in the treatment of chronic intestinal indigestion 
and constipation. 

Glycosuria. — Normal urine contains such a minute quantity of 
glucose that a positive reaction can not be obtained by the usual tests. 
Occasionally an appreciable amount may be detected in the urine 
of apparently healthy children ; but this is usually a physiological gly- 
cosuria, the result of the ingestion of an excessive quantity of carbo- 
hydrates. A pathological glycosuria, which is temporary, sometimes 
occurs in affections of the heart, lungs, liver, brain, and spinal cord; 
but when sugar is present in the urine in appreciable amount we are 
dealing with diabetes mellitus. The urine of infants fed on artificial 



THE URINE 531 

preparations frequently gives a positive reaction for sugar; and in 
some breast-fed babies the urine responds to Fehling's test, but not 
to the fermentation test, showing, perhaps, the presence of lactose and 
not glucose. 

Fehling's Test.— Fehling's solution, used for this test, deteriorates 
on standing, hence, for preserving, it is best made in two parts, and 
put in separate bottles; in this way it may be kept indefinitely. In 
one bottle, marked No. 1, keep the following: 

Pure copper sulphate 17.32 grama 

Distilled water 250.00 c.c. 



In another bottle, marked N 



o. 



Fkhling\s Alkaline Solution. 

Rochellesalt 87 .0 grama 

Caustic soda 25.0 

Distilled water 250.0 c.c. 

To make this test, mix in a test-tube equal volumes of Nos. 1 and 2, 
dilute with an equal quantity of water, and boil. No precipitate 
should be noticed. Now, slowly add to this mixture half its volume 
of urine, and again boil. The presence of glucose will be indicated by 
an orange or red precipitate. 

Pyuria. — Pyuria is that condition in which pus, from any cause 
whatsoever, is found in the urine. In children its origin is most 
frequently the bladder or pelvis of the kidney, but it may come from 
any part of the genito-urmary tract, or, in exceptional cases, from 
extraneous sources. This latter instance is best demonstrated by the 
rupture of a perinephric or appendiceal abscess into some portion of 
the genito-urinary tract. 

The appearance of urine containing pus depends upon the quantity 
present and upon its reaction. In acid urine, in which pus is usually 
of renal origin or due to the Bacillus coli or a tuberculous infection, 
the pus tends to settle as a dense deposit of a yellowish or greenish 
hue. In alkaline urine the pus is stringy and less circumscribed, and 
tends to cling to the sides of the containing vessel; it usually comes 
from the bladder. In pyonephrosis the discharge of pus is apt to be 
intermittent; in cystitis it is fairly constant; and when due to the 
rupture of a neighboring abscess into the urinary tract there is usually 
a copious discharge of pus for a time, followed by more or less rapid 
cessation of the pyuria. Rarely, during childhood, does pus in the 
urine come from the genital tract; but, exceptionally, it may be due 
to purulent urethritis or vulvovaginitis, and when this is the source 
the pus appears in flakes and is mixed with mucus. 

The only positive method of determining the presence of pus in 
the urine is by means of the centrifuge and microscope. The ropy 
condition produced by the addition of caustic alkali is often significant. 
The nature of the infection is of considerable importance, but can be 
demonstrated only by a culture from a catheterized specimen. 



532 DISEASES OF THE GEN I TO-URINARY SYSTEM 

Treatment. — The treatment of pyuria depends chiefly upon the 
cause. Because of its elimination in the urine, hexamethylenamin is 
of value in every case, regardless of the etiology. A child two years 
old should be given 2 grains every four hours. 

Dysuria. — Dysuria, or painful urination, is not uncommon in 
children and infants, and may be due to a variety of causes. Hyper- 
acidity and the passage of large quantities of oxalates or uric acid 
crystals frequently give rise to dysuria during infancy, and in child- 
hood the concentrated urine voided during fevers may be just as 
irritating. Small calculi are often passed by children; in these cases 
not only is there dysuria but severe colic attends the passage of the 
stone down the ureter. These calculi are frequently found on exam- 
ination to be lodged in the anterior urethra. Dysuria may also be 
caused by cystitis, urethritis, vulvovaginitis, and phimosis. 

In rare cases one meets with congenital anomalies which may 
render urination difficult and painful. In female infants there some- 
times exists at birth a membrane which covers the vaginal orifice 
and extends over the urethral meatus with but a minute opening 
through which the urine may filter out drop by drop. In these cases, 
urination is accompanied by great straining and pain, but the mem- 
brane can easily be divided with a blunt dissector, which procedure 
at once relieves the condition. Urethral caruncles are extremely rare 
in little girls; but occasionally in little boys painful micturition is 
caused by a condition of the urinary meatus in which the lips of the 
urethra are swollen and slightly everted, and on close examination 
is seen a small bead of granulations, which is very sensitive. The best 
treatment is to remove the granulations and stitch up the wound. 

In male infants there is occasionally a cellular adhesion of the pre- 
puce and glans penis, or a thin membrane over the urethral meatus, 
which causes difficult, and often painful micturition. In these cases 
the prepuce should be freed from the glans, and the membrane removed 
from the urethral orifice. Following circumcision, a painful crack or 
vesicle sometimes develops near the meatus and makes urination 
agonizing. A bland antiseptic ointment will protect the raw surfaces 
from the urine, and effect a speedy cure. 

Treatment. — The treatment of dysuria from other conditions is 
directed to the cause. If due to inflammatory processes along the 
genito-urinary tract, dysuria will ameliorate with improvement in 
the local condition; when due to hyperacidity, dysuria is relieved 
by the administration of alkaline diuretics and an increased intake 
of water. Potassium citrate, in a dose of 4 grains, t. i. d., in plenty 
of water, to a child of five years, is perhaps the most efficacious thera- 
peutic measure to be employed in hyperacidity. 

Anuria. — Anuria is that condition in which the kidneys fail to secrete 
any urine; it should be carefully distinguished from retention of 
urine, in which affection urine is normally secreted by the kidneys, 
but is retained in the bladder. When anuria occurs in the course of 
nephritis, it is referred to as "suppression of urine," In rare cases it 



THE URINE 533 

is due to congenital malformation of some portion of the urinary 
tract, but more commonly is a result of traumatism, of operative 
procedure, of the passage of a catheter, or the administration of ether 
or chloroform. Complete cessation of secretion by the kidneys has 
been observed in cases where children have in some way taken phenol, 
phosphorus, turpentine, cantharides, lead, bichloride of mercury, or 
other violent irritants to the kidneys. 

Many cases of anuria during infancy cannot be accounted for, 
although it is believed that a considerable number arc caused by uric 
acid infarcts of the kidney. Occasionally mere chilling of the body, 
a gastro-intestinal disturbance, or an acute infections disease will 
be the only demonstrable cause of anuria. Uremic symptoms appear 
very late in children with anuria; and in some instances in which 
there has been no secretion of urine for ten days recovery has occurred. 
Unless due to malformation or organic disease of the kidneys, anuria 
rarely persists over twenty-four hours, and in that time nothing 
abnormal may be noticed in the infant's general condition. When 
urine is not voided, it is important to ascertain whether we are deal- 
ing with retention of urine or anuria before attempting to treat the 
condition. This distinction can easily be made by the passage of a 
catheter, which will reveal a full bladder in retention, and an empty 
one in anuria. 

Treatment. — The general measures for the relief of anuria are hot 
fomentations to the loins, hot baths, and free purgation. To a child 
four years old 1 dram of magnesium sulphate in concentrated solution 
is, perhaps, the best saline cathartic to use. Sweet spirits of nitre, 
5 drops every hour, and potassium citrate, 3 grains hourly, should 
be administered until the urinary secretion begins. Colonic flushing, 
using normal saline solution at a temperature of 110° F., is often a 
valuable aid to this medication. Care must be taken not to inject 
too much fluid into the colon or it will not be retained, and the use 
of one pint at not less than six-hour intervals is, perhaps, the most 
efficacious mode of employing it. 

Retention of Urine. — Retention of urine to a mild degree Is not 
uncommon in young children, but rarely does a case come under 
observation which requires catheterization for relief. It may be the 
result of lodgment of a stone in the urethra, of urethritis, or of vagi- 
nitis. Phimosis, when extreme and due to edema or local infection, 
also reflex painful conditions of the anus and rectum, may cause 
retention; still other cases are due to myelitis, injury to the spinal 
cord, or hysteria. Simple retention of urine not due to organic causes 
is rarely productive of any symptoms, and may not cause the child 
the slightest inconvenience, although the distended bladder may be 
noticeable on inspection of the abdomen, and on percussion may be 
found to extend to the umbilicus. 

Treatment. — Immediate relief of retention is obtained by catheter- 
ization, but this is not always necessary, and quite frequently a small 
catheter mav not be available. A No. 6 American scale catheter may 



534 DISEASES OF THE GEN I TO-URINARY SYSTEM 

be used for infants, hut only after the application of heat to the 
suprapubic region and genitals has proven ineffectual. In every case 
the exciting cause should be ascertained and treated. In myelitis, 
nothing can be done but to catheterize. Hysterical children cease to 
have retention when their nervous systems are gotten under control, 
and those cases caused reflexly by painful conditions of the rectum 
and anus disappear when proper treatment is directed to the under- 
lying factor. Not infrequently investigation may reveal calculi in 
the anterior urethra of children which will clear up a puzzling case of 
retention for which no other cause could be demonstrated. 

Polyuria. — Polyuria is a temporary condition in which excessive 
quantities of urine are passed. It is a symptom of diabetes mellitus 
and chronic interstitial nephritis, and when chronic is called diabetes 
insipidus. Under ordinary conditions an increased consumption of 
fluid, or the decreased elimination of water by the sweat glands or 
bowels, will naturally result in polyuria, and certain drugs, among 
which are caffein, diuretin, and digitalis, materially increase the 
amount of urinary secretion. Polyuria is frequently observed in 
children with neurotic tendencies, and is often induced by exposure 
to cold or sudden fright in normal children. 

The absorption of dropsical fluids is accompanied by polyuria, and 
during convalescence from fevers children are apt to void a larger 
quantity of urine than usual. An interesting case is reported by Fowler, 
of a child who merely contracted the habit of drinking large quantities 
of water, and who had polyuria as a natural sequence. Chronic poly- 
uria, or diabetes insipidus, is usually due to organic lesions, and this 
is a clinical entity quite distinct from polyuria. 

Enuresis. — Enuresis is the term applied to incontinence of urine 
occurring in childhood, and is due to involuntary emptying of the 
bladder. Incontinence in the infant is normal; but, with careful 
training, continence at night should be established between the 
second and third years, and incontinence after the third year should 
be considered abnormal, and so treated. Continence during the day 
should be effected even earlier if the child receive proper training; 
after it is eighteen months old it should not wet itself during the 
day, and after the second year, if awakened and placed on the toilet 
twice each night, there should be no bed wetting. 

The term "nocturnal enuresis" is applied to bed wetting, and incon- 
tinence during the day is known as "diurnal enuresis." A child is 
most apt to wet the bed during the first few hours of sleep, for at this 
time sleep is most profound, and it is not awake aed by the desire to 
empty the bladder. Diurnal enuresis may complicate bed wetting, 
and these cases are the most persistent and obstinate to treat; but 
rarely does incontinence during the day exist alone. Nocturnal 
enuresis is usually associated with pollakiuria (frequent urination) 
during the day, and diurnal enuresis when not associated with bed 
wetting may be accompanied by incontinence of feces. 

Active incontinence is said to be present when sufficient urine 



THE URINE 535 

accumulates in the bladder to cause irritation of the sensory nerves, 
with contraction of the bladder walls from dilatation of the sphincter, 
resulting in a full stream of. urine which is rapidly passed. When 
passive incontinence exists there is weakness or paralysis of the 
sphincter vesicae, causing a continuous dribbling of urine. 

Etiology. — By far the greater number of cases of enuresis have 
a neurotic basis, and it is only exceptionally that an organic lesion. 
such as malformation of the urinary tract or paralysis of the sphincter 
vesicae, is found to explain this condition. Of the various mal- 
formations which cause enuresis little need be said; the more common 
ones are congenital vesicovaginal fistula, persistence of the urachus, 
extroversion of the bladder, and a congenitally small bladder. Par- 
alysis and deficient nerve innervation of the sphincter of the bladder 
are observed in spina bifida, idiocy, meningitis, brain tumor, myelitis, 
and injury to the spinal cord. 

Aside from these comparatively rare cases, due to organic disease 
of the nervous system, there is, in the vast majority of cases of 
enuresis, an unstable nervous system which is the direct result of age 
and heredity. During childhood the spinal cord and especially the 
motor nerves are so active, and the brain as yet so comparatively 
undeveloped, not having inhibitory control over the lower centres, 
that it remains only for some slight condition which will increase the 
irritability of the spinal centre or terminal filaments of the vesical 
nerves or interfere with the cerebral control over this centre to cause 
enuresis. 

The importance of heredity as a predisposing factor in enuresis is 
emphasized by the number of children with enuresis who display 
various other neurotic symptoms which indicate inherited neuro- 
pathic tendencies. In other instances the central nervous system 
has been weakened by chronic malnutrition, due either to improper 
feeding, unhygienic surroundings, enteritis, tuberculosis, or syphilis. 
The exciting cause of an initial attack is often an acute debilitating 
illness, and there is usually a recurrence of enuresis after such an 
illness, but there are various other exciting causes of enuresis. 

Whether there be a predisposition to enuresis of nervous origin or 
not, one will often find one of the following conditions to account for 
the affection. The urine itself may be at fault, examination revealing 
a highly acid or alkaline reaction, or there may be an excess of oxalates 
or uric acid crystals. Occasionally there is inflammation somewhere 
along the genito-urinary tract, either pyelitis, cystitis, or urethritis; 
less frequently one may discover calculi, tumors, or polypi, as a cause 
of irritation. Atony of the bladder, although hard to demonstrate, 
unquestionably exists in delicate, undernourished children; and in 
atony as well as in abnormal irritability of the bladder from infection 
along the urinary tract or irritation of nervous origin, may lie the 
explanation of many -obscure cases of enuresis. 

Various conditions are recognized factors in producing incontinence 
by reflex irritation; they comprise balanitis, vulvovaginitis, rectal 



536 DISEASES OF THE GEN I TO-URINARY SYSTEM 

polypi, fissure in ano, intestinal parasites, and constipation. In some 
cases, conditions even more remote, such as enlarged tonsils and 
adenoids, or thyroid insufficiency, may be considered etiological 
factors. Enuresis dependent upon diabetes mellitus or diabetes insipi- 
dus, should, perhaps, be attributed to the excessive quantity of urine 
excreted. In the home there is often a tendency to consider enuresis 
as purely a habit. This view may be erroneous, yet it is quite possible 
that enuresis may be the result of faulty training. There is no doubt 
that once the condition is established, its continuance is largely due 
to habit, a fact clearly demonstrated by its persistence after the 
recognized cause has been removed. Frequently, after careful study 
and investigation no cause can be found. Enuresis occurs with equal 
frequency in boys and girls, and is observed at all ages up to puberty, 
although the majority of cases are seen before the fifth year. 

Symptoms. — Ordinary enuresis is characterized by the complete 
evacuation of the bladder in a full, rapid stream; when there is con- 
stant dribbling an organic cause may be strongly suspected. Noc- 
turnal incontinence is by far the most common form, and may or may 
not be accompanied* by pollakiuria, while in diurnal enuresis pol- 
lakiuria is generally present. An attack of enuresis may be chronic, 
persisting from infancy until the seventh year; or it may be recur- 
rent, each attack being due to some slight disturbance. Temporary 
attacks are thought to be due to occasional hypersensitiveness of the 
bladder. The act of bed wetting usually occurs in the early evening 
when sleep is most profound, and in the morning when there is an 
accumulation of urine in the bladder. 

Diagnosis. — The diagnosis is self-evident, and is made by the child's 
parents. 

Prognosis. — The prognosis in enuresis depends on the underlying 
cause; but the age of the child and the duration of the symptoms 
have a marked influence on the rapidity of the cure. When there 
is organic disease of the brain or cord, or when malformations exist 
which are beyond surgical intervention, the outlook is, of course, 
hopeless. In the absence of these conditions the prognosis as to 
ultimate recovery is good. 

If some cause is discovered and removed, the case may clear up in 
a comparatively short time; but, as a rule, months of systematic, 
thorough treatment are required to bring about a cure, and no case 
should be pronounced cured until a year has elapsed without a return 
of the condition. Enuresis shows a strong tendency to cease spon- 
taneously without treatment at about the seventh year; for, by this 
time, the balance of the nervous system is fairly well established. 
Very rarely does it persist after puberty, although an occasional 
instance has been recorded in a neurotic girl. 

Treatment. — Prophylaxis with regard to enuresis consists in early 
training of the child and careful supervision of its habits of micturition 
and defecation. If taught to control its bladder and make known its 
desire to empty it, the child should have the mechanism of micturi- 



THE URINE 537 

tioD under cerebral control by the second year. Given a fully devel- 
oped case of enuresis to treat, the physician should first make a careful, 
systematic search for any condition which might possibly cause it. 
inasmuch as treatment directed to the symptom alone is, in most 
cases, a failure. 

The cooperation and confidence of the parents should be secured 
by telling them in the beginning of the chronicity of enuresis and its 
stubborn resistance to treatment. It is obvious that any predisposing 
cause should be removed; among these are phimosis, adherent pre- 
puce, adherent clitoris, vaginitis, vulvovaginitis, urethritis, pyelitis, 
pinworms, rectal polypi, fissures of the anus, and other reflex conditions. 

The urine should always be examined, and, if highly acid, the diet 
should be regulated, and the amount of proteins decreased; in addi- 
tion, potassium citrate in 3-grain doses may be given to a child of 
three years, and the amount of liquids increased if the urine is too 
concentrated. Excessive alkalinity may result from a diet too rich 
in starch and sugar; therefore, if this cause 4 of enuresis be discovered, 
it is well to limit the carbohydrate intake, and to give benzoic acid, 
2 grains three times a day, to a child three years old. If the quantity 
of urine passed is excessive, the amount of fluids taken by the patient 
must be restricted. 

Not infrequently, microscopic examination of the stained sedi- 
ment of a specimen will reveal the presence of the colon bacillus, 
showing an infection of the genito-urinary tract by this organism. 
Such an infection is accompanied by acidity of the urine and a highly 
irritable bladder, and requires the administration of potassium citrate 
and urotropin, of each 3 grains three times a day, to render the 
urine less irritating and inert. 

The bladder, itself, should be examined carefully, and if atony of 
the sphincter be found, galvanic or mild faradic currents may be 
applied or the neck of the bladder massaged through the rectum. 
Excessive irritability of the bladder, whether caused by urinary infec- 
tion or of nervous origin, demands the administration of vesical seda- 
tives, injections of normal saline or boric acid solution, and rest in 
bed. Sometimes a stone is discovered in the bladder, and its removal 
is always attended by cure. 

When remote conditions, such as enlarged tonsils and adenoids, 
are treated, the results are not nearly as good, with the possible 
exception of hypothyroidism, when the administration of thyroid 
extract usually effects a cure. Having remedied the cause of enuresis. 
the habit must usually be overcome before improvement sets in. One 
must consider that such a child is usually neurotic, and that, instead 
of harsh measures or punishments, it needs soothing but firm treat- 
ment. It should have the advantage of a change of climate to seashore 
or country, and be put on a good nutritious diet to build up the 
physical condition which in most cases is greatly impaired. Quiet 
is especially necessary, the nervous tension of present-day school life 
being a hindrance to treatment. 



538 DISEASES OF THE GENITO-URINARY SYSTEM 

Certain routine instructions should be given in each case. The 
child should be made to urinate before going to bed, and be awakened 
late in the evening and put on the toilet. The foot v of the bed should 
be elevated, and the child kept from lying on its back by means of 
a towel tied around the waist and knotted in the back. Sometimes a 
change from one bed to another will induce temporary relief. The 
diet should be bland and non-irritating; coffee, tea, and spices must 
be prohibited. The evening meal should be a light one, and no fluids 
be taken after 4 p.m. The bowels should be kept regular throughout 
the treatment, and no food or medication given that will irritate the 
urinary tract or produce constipation. 

If the child is anemic or chlorotic tonics, such as arsenic and cod- 
liver oil, are indicated and may be given with a few grains of sodium 
bromide added to each dose. The two most valuable drugs in the 
treatment of enuresis are belladonna and strychnine. Belladonna owes 
its effectiveness to its sedative action on the muscular wall of the 
bladder; it should be administered in increasing doses until the physi- 
ological effect is obtained. A child of three may take 1 drop of the 
tincture, three times a day, increasing it 1 drop daily until there is 
dryness of the throat and a flushed skin. It may then be reduced 1 
drop a day until the flushing ceases, and continued at this dose for 
several weeks. If there is no appreciable improvement after such 
administration of belladonna, it is useless to continue it. 

Tincture of nux vomica is indicated where the sphincter of the 
bladder is weak; this accounts for the particularly good results 
obtained by the use of this drug when diurnal and nocturnal enuresis 
are combined. The dose is 2 drops three times a day, to a child of 
three years. This dose may be cautiously increased. Ergot has 
been given for its tonic effect on the bladder wall, but it is the con- 
sensus of opinion that it is useless when belladonna and strychnine 
fail. 

Cathelin's treatment is worthy of trial and is justifiable when milder 
measures fail, for 80 per cent, of cures are recorded where it has been 
carried out. The patient is placed in Sim's lateral posture, and the 
coccygeal spine located. A lumbar puncture needle is introduced in 
the middle of a line joining the coccygeal cornua, and is passed directly 
upward, care being taken not to perforate the meninges. From 5 
to 25 c.c. of normal saline solution, at body temperature, are then 
slowly injected. The process is almost painless, and the child may be 
sent home as soon as it is done. In some cases a second injection is 
necessary ten days later. 

NEPHRITIS. 

Nephritis is not uncommon in children at any period from birth to 
puberty, and may occur in any of the types seen in adults. Our 
classification of the various forms of nephritis is still unsatisfactory, 
the term nephritis, itself, being restricted to non-suppurative inflam- 
mation of the kidney, thus making it necessary to use a qualifying 



NEPHRITIS 539 

adjective when a suppurative process is spoken of. Just as in adults, 
both acute and chronic nephritis occur in childhood, although the 
latter is rare; but, in addition to this classification, nephritis, as seen 
by the pediatrician, may well be classified etiologically. During 
infancy one may differentiate a distinct form of nephritis due to 
congenital syphilis, another arising from gastro-intestinal disturb- 
ances, a variety of other types produced by various infections and 
intoxications, as well as a type which resembles the contracted kidney 
of adult life. In older children one meets with nephritis which is 
usually secondary, and in which acute infections diseases play an 
important part as primary factors. Thus, we may divide these 
nephritides into the scarlatinal and diphtheritic types, and those due 
to other infections and intoxications of unknown or doubtful nature. 

Acute Congestion of the Kidneys. — Acute renal congestion, or renal 
hyperemia, is much more common in children than in adults because 
in the child it is so easily induced. The usual cause is an acute infec- 
tious disease; but it may be the result of severe digestive disturbance, 
high fever, irritating drugs used indiscriminately or taken acciden- 
tally, or of exposure to cold. 

Pathology. — The kidney of active congestion is slightly enlarged, 
swollen, and, after the capsule has been removed, appears brown or 
mottled. On section the cortex is wider and darker than in health, the 
bloodvessels are engorged, and the cells are the seat of cloudy swelling. 

Symptoms. — There are rarely any symptoms except a change in 
the urine, which may show albumin, with a few hyaline and granular 
casts. It is usually high colored, of high specific gravity, and scanty 
in amount — sometimes so scanty as to constitute partial suppression; 
yet rapid improvement is possible with no trace of kidney lesion 
remaining. The duration of the attack varies, recovery taking place 
promptly after removal of the cause. 

Treatment. — The child whose urine shows evidence of acute conges- 
tion of the kidneys should be kept in bed on a milk diet until recovery 
has taken place. It should drink plenty of water in order to dilute the 
toxins circulating in the blood and acting upon the kidneys, and 
increased excretion of toxins through the skin and bowels may be 
promoted by means of vapor or hot baths and saline cathartics. Hot 
applications over the kidney region act as mild counter-irritants, 
and relieve the feeling of discomfort usually present in the loins in 
this condition. 

Nephritis in Infancy. — No accurate estimate can be made as to the 
frequency with which nephritis occurs during infancy because of the 
difficulty in detecting its presence; this, however, makes it appear 
reasonable that it is more common than observations lead us to sup- 
pose. Several factors increase the difficulty of diagnosing nephritis 
in infants, not the least of which is the problem of collecting the urine 
in a suspected case; but far more puzzling is the frequent occurrence 
of nephritis without edema, also the possibility of both edema and 
albuminuria appearing in infancy with no demonstrable nephritis. 



540 DISEASES OF THE GEN I TO-URINARY SYSTEM 

Etiology. — Primary nephritis in infants is rare, although it is probable 
that many mild cases escape detection. Syphilis and gastro-intestinal 
disorders account for most of the cases, but one cannot ignore its 
association with bronchopneumonia, erysipelas, and extensive skin 
affections, when it may be considered as a complication. It is also 
a complication of the acute infectious diseases when, by chance, they 
occur in infants. Occasionally a case is reported of nephritis asso- 
ciated with scurvy. 

Pathology. — The syphilitic kidney exhibits microscopically an inter- 
stitial nephritis, but is normal to the naked eye, since there is no 
actual fibrosis, although the glomeruli and tubules may be imper- 
fectly developed owing to the syphilitic process. It is only excep- 
tionally that the preponderance of changes in the parenchyma justifies 
the diagnosis of parenchymatous nephritis, rather than the interstitial 
variety. 

The kidneys of an infant with nephritis of gastro-intestinal origin 
are also normal macroscopically ; but, in contradistinction to the 
changes in syphilitic nephritis, there is usually fatty degeneration of the 
epithelium of the convoluted tubules, but no change in the glomeruli. 

Symptoms. — Acute nephritis, whether of syphilitic or gastro-intes- 
tinal origin is, as a rule, latent. The infant with hereditary syphilis 
whose kidneys are affected rarely shows any symptoms. The urine 
contains albumin and casts, but is not diminished in quantity, and, 
when tested for blood, is negative. Uremia practically never occurs, 
and edema rarely is seen. It is not fatal, and its severity bears no 
relation to the degree of the other syphilitic manifestations, although 
it readily clears up under treatment which corrects the disease else- 
where in the body. 

The course of the disease is acute, and the symptoms latent. The 
nervous symptoms are very infrequent in nephritis of gastro-intestinal 
origin and in syphilitic nephritis ; but it is believed by some authorities 
that the symptoms referable to the nervous system which appear in 
the course of fatal gastro-ehteritis associated with nephritis may be 
uremic in character. The urine also shows more decided changes, 
and, in addition to albumin and casts, it sometimes contains blood. 

It is, apparently, only in the severe primary acute nephritis of 
infancy that symptoms and signs are the predominating features 
of the disease. Here the disease is usually a diffuse nephritis, but the 
involvement of the parenchyma is secondary to the interstitial lesions 
which are more pronounced. The symptoms are high but irregular 
fever, vomiting, diarrhea, dyspnea in severe cases, anemia, and 
nervous manifestations. The urine may or may not contain albumin 
at the onset; but, together with casts, it appears at some stage of the 
disease in every case. Although there is no edema, this form of neph- 
ritis is very grave, and a mortality of over 70 per cent, is recorded. 
As a rule, the nephritis associated with scurvy is latent, and albumin 
and casts in the urine may persist for months after the total disap- 
pearance of the scorbutic condition. 






NEPHRITIS 541 

Prognosis. — From the preceding description of the various forms 
of nephritis which occur in infancy it is evident that, with the excep- 
tion of the severe, acute, primary type, the prognosis as to life is good, 
the syphilitic form offering, perhaps, the best ultimate chance for 
recovery. Some clinicians believe that the acute interstitial nephritis 
of infancy is of chronic nature, and results in a contracted kidney, 
such as is observed in adult life. 

Acute Diffuse Nephritis. — Under this title will be included acute 
parenchymatous nephritis, acute exudative nephritis, acute desqua- 
mative nephritis, glomerular nephritis, acute tubular nephritis, and 
acute interstitial nephritis. 

Etiology. — From an etiological stand-point, the term acute nephritis 
may well embrace all the various forms of this disease enumerated 
above, since they all result from inflammatory changes produced by 
the action of toxins and bacteria. It is true, however, that the action 
of toxins alone is limited to degeneration of the epithelial cells of the 
kidney, while bacterial invasion of the kidney results, not only in 
degenerative processes in the epithelium, but also in infiltration of 
the kidney with newly formed cells which are probably the precursors 
of the fibrosis which follows. Infection of the kidney is quite fre- 
quently predisposed to by a degenerative condition of the organ 
induced by the action of toxins; but, in a few eases, usually severe in 
type, the bacterial infection occurs with no antecedent changes in 
the kidney structure whatsoever, as typified in the nephritis of the 
first week of scarlet fever or diphtheria. 

There can be no doubt that scarlet fever is the most common cause 
of nephritis in childhood. Why the kidneys should be so peculiarly 
vulnerable in this disease is not known; but the frequency with which 
scarlet fever is accompanied by acute inflammation of the kidneys is 
known the world over, even to the laity. The attack may have been 
mild, and the symptoms may have entirely disappeared; yet nephritis 
occurs which is suggestive of the operation of a variety of causes; 
and, although the toxin must be regarded as the primary factor, one 
cannot overlook the possible added effect of exposure to cold, errors 
in diet, constipation, and too short a period of rest in bed. 

The toxins produced in scarlet fever have a particularly selective 
action for the glomeruli. Acute nephritis is an earlier complication 
in diphtheria than in scarlet fever, but by no means as common; and 
the toxins of diphtheria injure both glomeruli and tubules. The 
proper use of diphtheria antitoxin is largely responsible for the com- 
parative rarity of nephritis as a complication of that disease. As 
a complication of the other common infections of childhood, nephritis 
is also comparatively rare; but it occasionally accompanies chicken- 
pox, epidemic cerebrospinal meningitis, measles, German measles, 
mumps, and whooping-cough. 

Other diseases of childhood which are sometimes accompanied or 
followed by nephritis are pneumonia, influenza, rheumatic fever, 
tonsillitis, typhoid fever, smallpox, tuberculosis, and, in the tropics, 



542 DISEASES OF THE GEN I TO-URINARY SYSTEM 

malarial fever. With septicemia and pyemia due to the streptococcus, 
staphylococcus, pneumococcus, or gonocoecus, febrile albuminuria 
is the rule, although nephritis is not uncommon. 

Certain extraneous substances, if ingested, are capable of producing 
nephritis and in their action resemble the toxins of scarlet fever and 
diphtheria; for instance, arsenic, cantharides, and snake venom affect 
chiefly the glomeruli; while bichloride of mercury, uranium nitrate, 
and potassium and ammonium chromate affect chiefly the tubular 
epithelium, attacking the glomeruli but slightly, if at all. Other 
exogenous toxins which cause nephritis, but whose selective action 
is as yet not clearly defined, are turpentine, carbolic acid, potassium 
chlorate, salicylic acid, oxalic acid, the mineral acids, alcohol, chloro- 
form, phosphorus, and lead. 

In addition to these toxic substances which are introduced from 
without the body, we cannot fail to recognize the importance of 
various toxins produced within the body; for instance, from the 
gastro-intestinal tract in digestive disorders, these being most marked 
during infancy, also in jaundice, in diabetes, and in children of gouty 
ancestry. The importance of cold as an etiological factor in the 
causation of nephritis has been greatly overestimated, as in all prob- 
ability it does nothing more than favor the action of pathogenic bac- 
teria, thus differing in no respect from its influence on inflammation 
of other organs of the body. 

Of the predisposing causes of nephritis, age and heredity are the only 
ones which influence this disease in childhood. There can be no 
question that the tendency to nephritis is sometimes transmitted; 
but this is infrequent because, in these cases, nephritis is chronic, 
whereas most of the cases of nephritis seen in children are of the 
acute type. 

Pathology. — In acute nephritis both kidneys are enlarged, are softer 
than usual, and have a more rounded appearance. The color varies; 
but, after removing the capsule which strips readily, the convex sur- 
face presents a pale, grayish, mottled appearance, with light red and 
quite dark red spots caused by hemorrhage and the congestion of the 
stellate veins. Upon incising the capsule the kidney substance may 
bulge through, and, upon sectioning, the cortex is found to be much 
swollen and grayish-yellow or light red in color. The pyramids seem 
unusually red in contrast with the pale cortex, its yellow areas or 
streaks marking the degenerated tubular epithelium. 

Microscopic examination shows involvement of the glomeruli, 
tubular epithelium, and interstitial tissue, the extent to which each 
is involved depending somewhat upon the cause of the nephritis. The 
glomeruli are swollen and hyperemic, and the capillaries are tense 
with blood that may be in thrombus form. Bowman's capsular space 
is filled with exudate and debris which cause pressure upon the vessels 
of the tuft and upon the tubules, markedly disturbing the function 
of the glomeruli, and accounting in some measure for the albuminuria, 
oliguria, and, perhaps, the increased blood-pressure of nephritis. 



NEPHRITIS • 543 

The tubular epithelium undergoes cloudy swelling and fatty degen- 
eration, and may desquamate; and the tubules themselves contain 
red blood cells, leukocytes, desquamated endothelium and casts. 
In cases of short duration, inflammatory edema, round-cell infiltra- 
tion, and hemorrhagic areas are found in the interstitial tissue; and, 
if the attack has been prolonged, there may be an increase in connec- 
tive tissue. There is an exudative type of acute diffuse nephritis which 
is observed in infants and young children and is characterized by 
large accumulations of leukocytes, serum, and red blood cells in the 
glomeruli and tubules, with either marked or but little change in 
the parenchyma and interstitial tissue. 

Symptoms. — Acute nephritis may manifest itself in two ways: 
either by an abrupt, frank onset with edema, pallor, headache, gastric 
disturbance, and conspicuous urinary changes, typified by scarlatinal 
nephritis; or by another type of the disease in which — though the 
onset may be sudden — there are no frank symptoms, and only by 
most careful study of the urine can any changes in its quantity and 
microscopic or chemical properties be detected. This latter form is 
characteristic of the acute nephritis which occurs during the course of 
typhoid fever or pneumonia. 

There are three symptoms of acute nephritis in children which arc 
fairly constant— edema, uremic manifestations, and urinary changes. 
The edema may be extreme and develop rapidly, although it some- 
times varies so greatly that the child may be entirely free from it for 
weeks and even months at a time. It is rather firm at the onset. 
and is most noticeable in the face in the morning, causing puffiness, 
swollen eyelids, watery eyes, and a pasty expressionless look which 
is characteristic. A similar puffiness of the fingers, ankles, the back 
of the hands, and scrotum occurs; later on there is infiltration of the 
subcutaneous tissues over the back and abdomen. The increase in 
weight is sometimes 40 per cent, of the previous body weight. 

As a rule, the urine is markedly diminished in quantity, and sup- 
pression is not uncommon. Albumin and casts are constantly present. 
and a trace of blood may be found occasionally. The color becomes 
Aery dark; the specific gravity is normal or slightly raised. One of 
the earliest signs of recovery is an increased output of urine. 

The usual temperature range is from 100° to. 103° F., but in very 
severe attacks it may reach 105° F. As a rule, the high temperature 
does not long persist, and a continuous elevation of temperature is 
to be regarded rather unfavorably. Headache, backache, extreme 
restlessness, and stupor are due to toxemia. In severe cases there may 
be uremic convulsions preceded by nausea, vomiting, deficient excre- 
tion of urea, and a urinous odor to the breath and perspiration. 

A fulminating type of nephritis may occur in which the onset is 
very abrupt, accompanied by high temperature, scanty urine, rich 
in albumin, casts, and blood. The pulse is full, of high tension, and 
there is severe pain in the lumbar region. Nausea, vomiting, and 
diarrhea, with extreme restlessness passing into stupor, signify the 



544 DISEASES OF THE GEN I TO-URINARY SYSTEM 

early approach of uremia; and, unless diuretic measures are prompt 
in relieving it, death rapidly ensues. Children, however, bear extreme 
oliguria and suppression of urine relatively better than do adults, 
and cases have been reported where suppression for three, five, or ten 
days was followed by recovery. 

Duration. — The duration of an ordinary attack of acute nephritis 
is usually from one to three weeks. It depends largely upon the 
severity of the particular case, and may be prolonged greatly beyond 
its usual course; but, in view of the fact that recovery may take place 
after six months or a year, one month seems but a short time. 

Complications. — The most frequent complications of acute nephritis 
are endocarditis, pericarditis, pleurisy, bronchitis, bronchopneumonia, 
and lobar pneumonia. Erysipelas, meningitis, and edema of the glottis 
are but rarely observed. 

Diagnosis. — The only possible way by which a physician can accu- 
rately diagnose the cases of acute nephritis in children which come 
under his care is to carefully examine the urine in all cases, and make 
daily urinalyses of his scarlet fever patients. He must carefully rule 
out cyclic albuminuria, febrile albuminuria, congestion of the kidney, 
infarcts, amyloid disease, tumors, and calculi before attributing 
urinary changes to acute nephritis. While it is desirable, if possible, 
to recognize acute nephritis by urinalysis before clinical signs and 
symptoms appear, the disease is occasionally not suspected until the 
characteristic appearance of swelling about the eyes and ankles, with, 
perhaps, fever, vomiting, and headache, leaves no doubt as to the 
diagnosis. 

Prognosis. — Acute nephritis is always a serious disease, yet the 
tendency in scarlatinal nephritis is to recovery, and the prognosis 
in severe acute nephritis is good if the case is properly managed from 
the onset until at least six months after convalescence begins. If 
not properly treated, a mild acute nephritis may pass into a chronic 
nephritis with doubtful prospects as to final cure. Acute nephritis 
in infants and young children often terminates fatally, and in a variety 
of ways; uremia is the most common cause of death in older children, 
but in the younger ones complications, especially of the respiratory 
tract, may lead to a fatal termination. 

Chronic nephritis was formerly thought to be an unusual sequel 
of acute nephritis in childhood, but we have been misled, perhaps, 
by the relatively long period of apparent health which may elapse 
between the initial attack and subsequent ones; therefore the least 
we can say is that the kidneys are left in a condition which renders 
them susceptible to future attacks. Of the various aids to prognosis 
in a given case of acute nephritis, the presence or absence of uremic 
manifestations and the amount of urine voided daily are, perhaps, 
the most reliable, although each case must be studied and judged by 
itself. 

Treatment. — Judicious treatment of any acute infection is the best 
prophylaxis of acute nephritis in childhood; therefore, in those dis- 






NEPHRITIS 545 

eases which are especially liable to cause nephritis precautions as to 
diet, clothing, catharsis, the use of drugs, and proper exercise, should 
extend well into convalescence. Since it is the irritation of the kidneys 
by toxins eliminated during the course of infectious diseases which 
causes nephritis, an attempt must be made by free catharsis and 
stimulation of the excretory function of the skin to eliminate these 
excrementitious substances when present in the urine. The urine 
may be rendered less irritating if we increase the daily output by 
restricting the patient to milk or buttermilk, whey, koumiss, Or 
junket, with, possibly, cereals and gruels at meal time, and fruit 
between meals. 

The value of diphtheria antitoxin as a prophylactic against nephri- 
tis has already been emphasized; but the abuse of other therapeutic 
agents, chief of which is the too free administration of certain drugs, 
may induce nephritis. Alcohol and urotropin are, perhaps, foremost 
in the list of harmful drugs; extreme caution must be observed also 
in the use of salicylic acid, potassium chlorate, phenol, mercury, and 
other recognized renal irritants. The effect of exposure to cold in the 
development of nephritis during the acute infections has probably 
been overestimated; but prolonged exposure to cold, and especially to 
dampness and cold, should, of course, be avoided. 

The active treatment of acute nephritis should be undertaken with 
three objects in view; viz., the removal of the cause; the reestablish- 
ment of kidney secretion and the securing of rest for these organs by 
increasing elimination through the skin and bowels; and the treat- 
ment of symptoms and complications. Removal of the cause of 
acute nephritis may be brought about by the prompt and efficacious 
treatment of an existing infectious disease, or by discontinuing the 
use of such drugs as are known to irritate the kidneys. In order to 
lessen the work of the now crippled kidneys, free saline catharsis 
should be induced by the use of magnesium sulphate in 2-dram doses 
daily to a child of five years, and the skin kept acting freely by means 
of frequent sponges and warm baths, and not allowing the temperature 
of the sick room to fall below 70° F. 

The diet should consist of food which will not aggravate the inflam- 
mation of the kidneys. For a child of five years, 21 ounces of milk 
daily, given 7 ounces at a time with a little cereal, and supplemented 
by some apple sauce or jelly, with stale bread or zweibach between 
meals, meets this requirement and is amply sustaining. This diet 
should be insisted upon for a month after the first trace of albumin 
makes its appearance in the urine, and the only indication for increas- 
ing it is the advent of anemia or steady loss of weight. Cognizant 
of the fact that in individuals with apparently healthy kidneys the 
ingestion of sodium chloride is followed by chloride retention which 
equals that in mild nephritis, the value of a salt-free diet is apt to be 
overestimated; but in all forms of nephritis associated with renal 
edema the restriction of sodium chloride to 1 or 2 grams (15 to 30 
grains) daily for a child of five years is desirable, and only when edema 
35 



546 DISEASES OF THE GEN1 TO-URINARY SYSTEM 

is marked should a salt-free diet be advised; even in this case it should 
not be maintained for a long period. The proteins ingested should 
never exceed an ounce a day, and a diet of fats and carbohydrates 
leaves less residue in the shape of solids for elimination through the 
kidneys. Fruits, such as oranges, grape fruit, apples, either baked 
or made into sauce, and lemonade form an acceptable addition to 
the diet, and are not injurious, in some instances acting as diuretics. 
Rest in bed is imperative, and should be insisted upon until albumin 
and casts have permanently disappeared from the urine. 

Change of climate is only to be considered in subacute and chronic 
cases, for the danger of overexertion or exposure to cold makes travel- 
ing undesirable; the child is much better off at home under proper 
treatment. 

Severe cases of nephritis marked by high fever, partial suppression 
of urine, and intense edema, require more active and radical proced- 
ures. The hot pack and vapor bath should now be resorted to for 
increased stimulation of the skin, and an effort be made to increase 
diuresis by the application of hot flaxseed or mustard poultices to the 
loins, or by dry cupping. Colonic flushings, using a pint of normal 
saline solution at 110° F. for a child of five years, will, often increase 
the kidney action, and should be repeated every six hours until effec- 
tive. Tincture of aconite, in 1-drop doses for a child of five years, 
may be repeated every two hours until there is slight diaphoresis; 
and nitroglycerin, 2iro °f a grain may be given hourly until the high- 
tension pulse is relieved. 

If uremia supervene, the convulsions can sometimes be controlled 
or prevented by the hypodermic administration of morphine, ^V °f 
a grain at a dose for a child of five years. Venesection is advisable 
in severe attacks, and though extremely difficult because of the 
collapsibility of the veins in children, at least a half -pint of blood 
should be withdrawn and a pint of normal salt solution injected. 
The withdrawal of a test-tubeful of spinal fluid by lumbar puncture 
gives relief in some cases, and may be tried in extremity. If the heart 
grows weak, tincture of strophanthus should be administered in 3-drop 
doses, every three hours, to a child of five years. Other symptoms 
may necessitate special treatment. If the edema be severe, paracen- 
tesis of the abdomen or pleura and puncture of the legs is sometimes 
required. Edema of the larynx may necessitate tracheotomy. 

Convalescence is tedious; the anemia so often present is improved 
by the administration of Basham's mixture (liquor ferri et ammonii 
acetatis), in 1-dram doses to a child of five years. Sudden exposure 
to cold should be carefully guarded against, and exercise taken very 
moderately. The diet should be cautiously increased, avoiding much 
nitrogenous food. With convalescence fairly well established, or if 
the disease shows a tendency to become subacute, it is perhaps advis- 
able to send the child to a warm equable climate; the winters, 
especially, should, if possible, be spent in Florida or Southern Cali- 
fornia. 



NEPHRITIS 54; 

Chronic Nephritis.— Chronic nephritis is one of the rare diseases 

of childhood. It is almost unknown in infancy, and practically never 

observed before the third year, most cases occurring between the 
fifth year and puberty. There are three forms of chronic nephritis 
in children which conform more or less to the adult types; L c, chronic 
parenchymatous nephritis (chronic diffuse non-indurative nephritis); 
chronic interstitial nephritis (chronic diffuse indurative nephritis); 
and the waxy or lardaceous kidney. The chronic parenchymatous 
type may assume the characteristics of the chronic interstitial variety 
as the disease progresses. Amyloid disease, which causes the waxy 
kidney, is a degenerative proces> which may be engrafted on a chronic 
nephritis of childhood. 

Etiology. — The direct relation of chronic nephritis to acute nephritis 
in childhood is definite, which i> in sharp contrast with the obscure 
connection between these two diseases in adult life. Most cases follow 
acute scarlatinal nephritis and, less frequently, the other acute infec- 
tions. Amyloid disea^e of the kidney is most apt to be the sequel of 
syphilis, tuberculosis, chronic suppuration, rachitis, or chronic malaria. 
Hereditary syphilis may account for that very rare form of chronic 
nephritis in childhood — the interstitial variety — in which a gouty 
ancestry, tuberculosis, alcoholism, and chronic valvular heart disease 
are supposed to be predisposing factors. The occurrence of chronic 
nephritis in more than one child in a family also suggests the possible 
influence of heredity. All the other etiological factors of acute neph- 
ritis may be considered capable of indirectly producing a chronic 
nephritis. 

Pathology. — The lesions produced in the kidneys by the three 
types of chronic nephritis which occur in childhood do not differ 
essentially from those observed in adult life. The kidney in chronic 
parenchymatous nephritis is enlarged, pale, of decreased consistence, 
and has a smooth surface; the capsule is not adherent. On section 
the cortex is found to be wider than normal and yellowish-white 
in color, on account of which it is called the "large white 
kidney." 

The microscope shows the convoluted tubules to be thickened and 
dilated, the epithelium undergoing granular and fatty degeneration 
and exfoliation, but only exceptionally are the tubules atrophied. 
The glomeruli may be either compressed and atrophied or may show 
hyaline changes, swelling, cellular proliferation, and desquamation. 
The large red kidney — the result of multiple hemorrhages in the cortex 
— and the small white kidney, which is the same size or even smaller 
than the normal organ, are rarer pathological forms which the kidney 
may assume in chronic parenchymatous nephritis. 

In chronic interstitial nephritis the kidneys are usually much 
atrophied, and appear drawn or shrunken, hence the synonym "con- 
tracted kidney." They are red or reddish-gray in color, and the cortex 
is much thinner than usual. The capsule is firmly adherent and strips 
off with difficulty, exposing a coarse, granular kidney surface. The 



548 DISEASES OF THE GEN I TO-URINARY SYSTEM 

most characteristic microscopic change noted is the marked increase 
in fibrous tissue distributed irregularly throughout the kidney 
structure. 

Other changes may be practically the same as those observed in 
the chronic parenchymatous type. The tubules in one part of the 
kidney may be completely atrophied, and in another they are dilated, 
forming cysts. If no chronic congestion of the kidney has preceded 
the inflammation, the glomeruli are 'atrophied; but if chronic conges- 
tion has taken place they may be large, the capillaries dilated, and 
the walls showing hyaline degeneration. Cardiovascular lesions are 
commonly present, and include atheroma of the arteries and cardiac 
hypertrophy. Cirrhosis of the liver is occasionally seem 

In amyloid disease the changes are not confined to the kidneys, but 
these organs are considerably enlarged, grayish in color, and of putty- 
like consistency. The lardaceous material is most abundant along 
the renal vessels and in the vascular tufts of the glomeruli, and the 
kidney substance atrophies as the amyloid deposits increase. Other 
organs, such as the suprarenal glands, spleen, liver, and intestinal 
villi are also involved. 

Symptoms. — Chronic Parenchymatous Nephritis. — The onset of this 
form of chronic nephritis is usually an exacerbation of an acute attack 
of nephritis which in some cases immediately precedes it, while in 
others it may be separated from it by months or even years. Rarely 
do we find a case which is chronic from the beginning, with insidious 
onset, and resembling the adult type; yet the undoubted existence 
of such in later childhood demands recognition. 

The physicianjs usually consulted on account of indefinite symp- 
toms, such as malaise, anorexia, pallor, gastro-intestinal disturbances, 
or slight puffiness of the ankles or about the eyes. There may be 
dropsical accumulations in other parts of the body, even effusions 
into the pleura, pericardium, or peritoneum; but the amount of 
dropsical fluid varies greatly, being markedly increased during exacer- 
bations, and diminished or entirely absent at other periods. Anemia 
is always present, vomiting is common, and various nervous phe- 
nomena, such as drowsiness, insomnia, fatigue, headache, and neuralgia 
are frequently observed. Unless there are complications there is no 
fever in chronic nephritis. 

The amount of urine is diminished, but the daily output varies 
greatly during the course of the disease. The reaction is acid, the 
specific gravity normal or a little above normal, and on standing there 
is an abundant sediment of urates, casts, epithelial cells, and blood 
corpuscles. Albumin is constantly present, and greatly increased 
during exacerbations, the total amount lost during the day reaching 
as high as 20 grams (5 drams). The number of casts is usually in 
direct proportion to the amount of albumin in the urine. They are 
hyalin, granular, epithelial, and fatty, with broad outlines; oil 
globules may be perceived upon many of them. Free fat droplets 
are often found; but red and white corpuscles are not abundant in 



NEPHRITIS 549 

the urine of chronic parenchymatous nephritis except during acute 
exacerbations. 

Lardaceous or waxy degeneration of the kidneys is associated 
with greater ascites, also with amyloid deposits in the liver, spleen, 
and intestinal canal which cause enlargement of these organs, and 
often obstinate diarrhea which renders the prognosis grave. The 
urine is pale yellow in color, of low specific gravity, and contains 
hyalin and waxy casts. Albuminuria and polyuria are usually present, 
but there is rarely blood in the urine, and but little sediment on 
standing. Mild cases are not recognized because, instead of the 
typically weak, pale, cachetic, emaciated child with muddy com- 
plexion, the patient may have a good ruddy complexion, be fairly 
strong and fat, and show no evidence of dropsy. 

The duration of these forms of renal disease depends largely upon 
the surroundings of the patient, the amount of renal tissue involved, 
and the treatment. Pulmonary edema not infrequently brings chronic 
parenchymatous nephritis to a fatal termination, and in both of these 
diseases death is usually due to pneumonia, pericarditis, pleurisy, or 
endocarditis. Uremia is uncommon in children; when it does occur, 
it is usually associated with chronic interstitial nephritis. 

The symptoms of chronic interstitial nephritis seem in many cases 
to date from birth, but they are indefinite, vague, and few in number. 
The child is pale and delicate from infancy, anemic, and usually 
stunted in growth; but, when the case comes under observation, 
anemic pallor may be replaced by a peculiar dusky flush, due to capil- 
lary congestion. Dropsy is rare. The blood-pressure, high with hyper- 
trophy of the left ventricle, and atheromatous changes in the arteries 
are not infrequent. Nervous disturbances are common, and include 
headache, neuralgia, albuminuric retinitis, retinal hemorrhages, and 
attacks of spasmodic dyspnea; toward the end of the illness convulsions 
and cerebral hemorrhage may also occur. The urine is pale, of low 
specific gravity, increased in quantity, and voided frequently in large 
amounts. The sediment is quite scanty; under the microscope it 
is found to be composed of a few epithelial cells, a few hyaline or 
granular casts, and an occasional red or white blood corpuscle. 

Diagnosis. — In the early stages of the disease when few symptoms 
appear, chronic nephritis may be easily overlooked and not diag- 
nosed until after careful urinalyses have been made, since albumin 
and casts may be present in the urine for quite a while without 
the appearance of any other symptoms of nephritis than anemia. 
Children presenting symptoms such as convulsions, persistent or 
frequent headaches, or cardiac hypertrophy with high arterial ten- 
sion, and all cases of general malnutrition, should have their urine 
carefully examined, for it is failure to examine the urine of children 
routinely that accounts for the frequency with which chronic nephritis 
is undiagnosed in childhood unless it be accompanied by frank symp- 
toms, such as dropsy with scanty urine. If the urine be carefully 
examined, functional albuminuria is the onlv condition which can 



550 DISEASES OF THE GEN ITO-URI NARY SYSTEM 

possibly need to he differentiated Prom chronic nephritis, and organic 
renal disease can be excluded only after repeated and thorough urinary 
analyses. 

Prognosis. — One who expects permanent recovery from chronic 
nephritis will, in the majority of cases, be disappointed. Although 
these patients may live for a number of years with comparatively 
few symptoms, the outlook as to ultimate or complete recovery 
is unfavorable. The prognosis, also, largely depends on the circum- 
stances of the parents; for, in the parenchymatous type particularly, 
life can be prolonged and made tolerable for years if the child can be 
kept midst ideal surroundings in an equable climate. 

Chronic interstitial nephritis offers the least favorable prognosis; 
and in chronic parenchymatous nephritis, or cases of waxy kidney, 
the outlook is serious when there is a persistently increasing amount 
of urine of low specific gravity, this indicating fibrotic changes in the 
interstitial tissue and Malpighian tufts. Other unfavorable signs in 
chronic nephritis are a considerable amount of dropsy, valvular disease 
of the heart associated with nephritis, and a greatly diminished output 
of urea. 

Treatment.— The principles of treatment in chronic nephritis are 
the same that apply in the acute form. The child should be carefully 
protected from any influence which might lead to an exacerbation. 
To this end, excessive muscular exertion, exposure to the acute infec- 
tions, chilling, drugs that irritate the kidney, and dietetic errors 
should be avoided. Since outdoor life is very beneficial, it is always 
advisable to reside in a climate where the winters are mild. 

Rest in bed is indicated only when there are uremic symptoms or 
large dropsical accumulations. While the child is in bed, the diet 
should be the same as that prescribed in acute nephritis. If it be up 
and about, the list may include fats, carbohydrates, well-cooked green 
vegetables, cereals, fruits, simple desserts, and meat three times a 
week. Of course, food or drinks known to be renal irritants should 
be avoided, and no salt should be added to any food except what is 
used in making bread. Water or milk may be taken as beverages in 
such quantities as the child may desire. The clothing should be warm, 
and woolens may be worn next the skin all the year. 

Good elimination through the skin and bowels is important. A 
daily warm bath at 95° to 100° F. is of great benefit, and saline 
cathartics are advisable to keep the bowels active, especially if there 
is much edema. Diuretics also are indicated when edema is marked, 
and, for a child of five years, 1 dram of liquor ferri et ammonii acetatis, 
given three times a day, has the additional advantage of supplying 
iron to the impoverished blood. In severe cases cardiovascular 
stimulation is necessary. 

If uremia develops, nitroglycerin in doses of y^~q °f a grain may be 
given every hour to lower the pulse tension ; even venesection may be 
resorted to. Uremic convulsions may require the hypodermic injec- 
tion of morphine or the rectal injection of chloral hydrate. Active 



PERINEPHRITIS 551 

diuresis catharsis, and diaphoresis should be induced by the measures 

outlined in the discussion of the treatment of acute nephritis. In 
eases of chronic nephritis which fail to improve under medical treat- 
ment, and in which the specific gravity and urea output are constantly 
falling and uremia impending, Edebohls' operation of splitting the 
capsule of the kidney, while not curative, should be resorted to, for 
it sometimes prolongs life and adds greatly to the comfort of the 
patient. 

PERINEPHRITIS. 

Perinephritis is an inflammation of the tissues surrounding the 
kidney. As discussed in this article, the term perinephritis includes 
inflammation of the fibrous capsule, of the fatty capsule (epinephritis . 
and of the retroperitoneal fat (paranephritis). It is a rare condition 
in children, and usually terminates in absces> formation, although 
resolution may occur. 

Etiology. — Perinephritis is usually a secondary affection, arising 
either from metastasis, the infection being carried by the blood or 
lymph stream, or by direct extension from a neighboring focus of 
inflammation or suppuration, such as a psoas abscess, rectal abscess, 
a pyonephrosis, or an appendicular abscess. The primary form is 
very uncommon; it usually develops from penetrating wounds, con- 
tusions, and blows in the region of the kidney, while some cases may 
be traced to a sudden strain, the lifting of heavy weights, or even 
exposure to cold. 

Perinephritis, as met with in the acute contagion-, i> believed to 
be due to secondary pyogenic infection rather than to the primary 
disease. Bacteria are always the immediate cause, and the various 
organisms which may be responsible include staphylococci, strepto- 
cocci, and pneumococci; influenza, colon, typhoid, and tubercle bacilli. 
In many cases no assignable cause can be discovered. Right and 
left kidney regions are affected with equal frequency, and both sexes 
are equally liable to the disease. 

Pathology. — Abscess formation in this region of the body does not 
differ essentially from that occurring elsewhere. Pus may burrow 
down along the ureter into the pelvis, or form a fluctuating mass 
beneath the liver or spleen, or come to the surface posteriorly near the 
middle of the intercostal space, or point just above Poupart's ligament, 
or discharge its contents into the peritoneal cavity, vagina, or bladder. 

Symptoms. — In primary cases the onset is acute with fever, and the 
symptoms are referred definitely to the perinephric region, while 
secondary perinephritis is apt to be masked by symptoms of the pri- 
mary disease, and may not be recognized until a soft, fluctuating tumor 
is detected on bimanual examination. Pain in the lumbar region with 
tenderness on pressure is usually the first symptom, and may be 
extremely severe. The leg is held semiflexed, and extension is very 
painful; but it may be flexed on the abdomen without discomfort. 
There is no fixation of the hip-joint. Fever is variable and usually 



552 DISEASES OF THE GEN I TO-URINARY SYSTEM 

intermittent, but may be remittent, or continuous; high, low, or 
absent; and in acute cases is preceded by a chill. 

In the early stages there is no local swelling; but when the disease 
has existed for some time, a distinct tumor appears in the back, and 
by palpation a smooth, elastic mass, usually fluctuating and generally 
fixed, but not affected by respiratory movements, can be made out. 
Symptoms referable to the kidneys are present only when the inflam- 
mation involves these organs; hence the urine is, as a rule, normal, 
but if pyelitis exists it contains pus. As the disease progresses, lame- 
ness and deformity become prominent symptoms. There is deviation 
of the spine, its concavity being toward the affected side; pain is so 
increased by movements of the limb that standing or walking is 
rendered impossible. 

Course. — The duration of perinephritis, primary in nature, is usually 
from one to two months, as recovery generally proceeds rapidly after 
evacuation of the pus; but secondary perinephritis is slow and insid- 
ious, and may last six months. 

Diagnosis. — Hip-joint disease is so closely simulated by perinephritis 
that careful investigation and study are necessary to exclude it, espe- 
cially if there be no localized abscess. Acute cases of perinephritis 
are, of course, differentiated by the rapidity of onset and the general 
symptoms of an acute inflammatory process; even those cases which 
are subacute or chronic in character run a different course and are 
never so insidious or chronic as hip-joint disease. There is also a 
marked difference in the limitation of motion which these two diseases 
cause; for, while in perinephritis there is only interference with 
extension of the thigh on the affected side, in hip-joint disease all 
movements of the joint are restricted, and there is tenderness in the 
hip-joint with pain which is frequently referred to the inner side of 
the knee. Psoas abscess from Pott's disease may cause deformity 
and lameness and thus simulate perinephritis; but on examination 
we find rigidity of the spine, angular prominence, and other evidences 
of spinal caries. Early diagnosis of perinephritis is always difficult 
because of the absence of tumor and the masking of the symptoms 
by the primary disease. In doubtful cases, puncture is justifiable, 
and the x-ray may sometimes be helpful. 

Prognosis. — In primary perinephritis the prognosis is good, and the 
majority of cases in children terminate in recovery. If the abscess 
points externally this is invariably the case, especially if there be 
early surgical interference. The only condition likely to prove fatal 
is rupture of the abscess into the peritoneal cavity. Occasionally a 
persistent fistula results, but, as a rule, recovery is complete. 

Treatment. — The patient should be put to bed and treated symp- 
tomatically until the diagnosis is made with certainty. Pain may 
be relieved by hot applications and poultices to the affected side, but 
is occasionally so severe as to require the use of morphine hypoder- 
matically. When the diagnosis is established, and abscess formation 
becomes apparent, but one procedure is indicated; i. e., the abscess 



TUBERCULOSIS OF THE KIDNEY 553 

must be freely opened and drained, and all pockets of pus broken 
up to prevent burrowing and subsequent rupture into the peritoneal 
cavity. If any kidney involvement be suspected, this organ should 
be palpated or even incised, and nephrotomy or nephrectomy be 
performed, as the condition demands. 

TUBERCULOSIS OF THE KIDNEY. 

It is questionable whether, in the true sense of the word, there are 
any cases of primary renal tuberculosis; and in children, tuberculosis 
of the kidney, without clinical evidence of the disease in other parts 
of the body, is extremely rare. In general tuberculosis in children the 
kidneys are usually involved, but the knowledge that the kidneys are 
studded with miliary tubercles helps little, if any, in the subsequent 
treatment of miliary tuberculosis, and this phase of renal tuberculosis 
is, therefore, of little importance. When, however, tuberculosis of 
the kidney occurs with no demonstrable active lesions elsewhere, the 
so-called "primary renal tuberculosis," it tends to remain localized 
in the kidney, and prompt and proper treatment is followed by brilliant 
results in a large proportion of cases. 

Etiology. — Miliary tuberculosis is by far the most frequent cause of 
renal tuberculosis in children; the infection is hematogenous, and 
both kidneys are involved. Hematogenous or descending infection 
may arise also from some focus of tuberculosis elsewhere in the body. 
independent of general tuberculosis. Ascending infection from other 
parts of the genito-urinary tract is extremely rare; but infection 
by continuity from some adjoining focus, such as spinal caries, from 
tuberculosis of the adrenals, or from tuberculous empyema is occa- 
sionally seen. 

Pathology. — In general tuberculosis the kidneys, when involved, 
show many small tubercles which cover the surface and are dissemi- 
nated throughout the substance of both organs. So-called "primary 
tuberculosis" is usually unilateral, and involves first the cortex, then 
the mucous membrane of the pelvis and calices to the pyramids, so 
that, in advances cases, nearly the whole organ may be destroyed and 
replaced by caseous material. Perinephric inflammation is quite com- 
mon in renal tuberculosis as the result of direct extension; the other 
kidney may become involved by metastasis or, in rare instances, 
by direct extension via the bladder. The second kidney may also 
show signs of hypertrophy, of chronic fibrosis, or of amyloid degen- 
eration. 

Symptoms. — In acute miliary tuberculosis, involvement of the 
kidneys is rarely accompanied by any symptoms, and in the primary 
type of renal tuberculosis the symptoms, particularly at the onset, 
are vague and indefinite. There may be pain and tenderness in the 
region of the kidney after the disease has become established, but 
the first symptom is usually frequency of urination, with burning and 
cramp-like pains which increase toward the end of micturition and 



554 DISEASES OF THE GEN 1T0-URI NARY SYSTEM 

cease when the bladder is empty. Incontinence is occasionally present. 
In uncomplicated cases the urine is acid in reaction, and contains 
albumin, pus cells, blood, and tubercle bacilli. 'Constitutional dis- 
turbances develop late, and include fever and digestive disturbances, 
while toward the close of the disease emaciation, anemia, and cachexia 
become marked. 

Diagnosis. — The diagnosis is made by the symptoms and signs of 
tuberculosis elsewhere in the body, and by localized manifestations 
of kidney disease, such as pain and swelling on the affected side, and 
is confirmed by finding the tubercle bacilli in uncontaminated urine 
from the kidney. 

Prognosis. — The prognosis in unilateral renal tuberculosis which is 
recognized early and treated by nephrectomy is good; but, of course, 
there is the danger of the operation. In bilateral tuberculosis of the 
kidney and in miliary tuberculosis the outlook is unfavorable. 

Treatment. — Nephrectomy offers the only hope of real cure. Lesser 
operations, such as nephrotomy or nephrostomy, are justifiable only 
when the child's condition renders nephrectomy impossible. Opera- 
tion should be followed by the general curative measures employed 
in treating tuberculosis, such as fresh air, sunshine, good nutritious 
food, and suitable climate. 

RENAL CALCULI. 

Large calculi are very rarely observed in children under four years 
of age, but in infancy there is a marked tendency to the deposition 
of fine granules of uric acid in the pelvis and calices of the kidney. 
These deposits have been found in more than one-half of the infants 
who live for only a few w T eeks, and are for the most part composed 
of uric acid. Under ordinary circumstances these crystals are dis- 
lodged during early infancy, and pass out in the urine. The affection 
is not accompanied by any severe symptoms, unless the granules 
be large, and should pass away at the end of the first or second week. 
Xo renal lesions follow, so that there is no danger to life, and the free 
administration of water will soon dissolve the deposits. The chemis- 
try of larger renal' calculi and the mechanism of their formation, as 
well as the symptoms, are the same as in the adult. 

Etiology. — True calculi are composed of uric acid, calcium oxalate, 
and phosphatic concretions of which bacteria and cellular detritus 
usually form the nucleus. 

Symptoms. — The passage of small uric acid granules is usually 
attended with no symptoms aside from their appearance on the 
infant's napkin, which is sometimes a matter of great concern to the 
parents. When, however, the stone is of such size that it passes down 
the ureter with difficulty, it produces paroxysms of excruciating pain, 
which is apt to be referred to the umbilicus, and also symptoms not 
unlike those of intestinal colic. In severe cases there may be nausea, 
vomiting, convulsions, and often collapse, until the stone reaches 



TUMORS OF THE KIDNEYS 555 

the bladder, when these symptoms usually cease. It', however, the 
stone becomes impacted and completely blocks the ureter, no mine 
is passed, and hydronephrosis followed by pyonephrosis or pyeloneph- 
rosis quickly develops. The older the child the more closely do the 
symptoms of renal calculi adhere to the adult type; pain is referred 
along the ureter to the loins and thigh of the affected side, and may 
be rerlexly felt in the penis. There is usually hematuria. The testicle 
on the affected side may be drawm up to a higher level than its fellow. 
The passage of a stone through the urethra will cause the child to 
run about in pain, grasping the penis, and if the stone is not passed 
it is not uncommon after an attack like this to find it lodged in the 
urethra. In well-marked cases there may be slight fever, indicating 
pyelitis, with pain over the affected kidney, marked tenderness in 
this region, and accompanying pyuria. Occasionally renal calculi 
are found at autopsv which have given rise to no symptoms during 
life. 

Diagnosis. — The diagnosis of renal calculus is sometimes very 
difficult, but the presence of any of the foregoing symptoms, especially 
when urinalysis reveals pus or blood, is strongly suggestive. The 
z-ray is of actual use only when a positive result is obtained; but 
should be resorted to in every case, as by its aid we frequently dif- 
ferentiate renal calculus from appendicitis. In infancy, immediate 
diagnosis from intestinal colic is impossible. 

Treatment. — Surgical measures are warranted only when the presence 
of a large stone in the kidney or ureter can be demonstrated, and is 
giving rise to severe symptoms. In milder cases symptomatic treat- 
ment is usually sufficient. It consists in the administration of plenty 
of water, and the correction of a highly acid or alkaline urine by appro- 
priate medication. Citric or acetic acid may be given for excessive 
phosphatic concretions, hexamethylenamin, in 2-grain doses every 
four hours to a child of five years, if the deposits be of uric acid; while 
oxalic acid crystals call for the internal use of sodium phosphate. In 
some cases the pain may be relieved by the application of heat either 
as a poultice or hot bath; but not infrequently the hypodermic 
administration of morphine with atropine is necessary to relieve pain. 
General measures, such as regulation of the diet, with avoidance of 
red meat, plenty of outdoor exercise, and careful attention to the 
bowels, hasten recovery, and are prophylactic as regards future attacks. 

TUMORS OF THE KIDNEYS. 

Benign tumors of the kidney rarely occur during childhood, but 
malignant growths are comparatively frequent, usually of develop- 
mental origin, and sarcomatous in type. When benign tumors do 
appear in children they generally prove to be adenomas, fibromas, 
lipomas, or cysts, and, because of their slow growth, they cause few 
if any symptoms, remain undiscovered, and, practically, are seen only 
at autopsy. The most common malignant tumor in this situation is 



556 DISEASES OF THE GEN I TO-URINARY SYSTEM 

the adenosarcoma, which is almost always primary. In some instances 
it contains several varieties of epithelial, adenomatous and connective- 
tissue elements. 

Malignant tumors may form in the cortex or pelvis, and either 
invade the interior of the kidney or project from its external surface. 
As they adhere to surrounding tissues, and enlarge rapidly, they may 
fill the whole abdomen in a relatively short time. Malignant growths 
are, as a rule, very soft, and rarely cystic; they frequently show a 
tendency to hemorrhage within the substance of the tumor. 

Ascites, hydronephrosis, and thrombosis of the vena cava may 
result from pressure, but general peritonitis rarely develops, although 
the growth may attain great size, not uncommonly weighing from 
five to ten pounds, and, in rare instances, even fifteen pounds. Metas- 
tasis is common, resulting in involvement of the liver, the lungs, the 
other kidney, the mesenteric nodes, the colon, the small intestine, 
and the adrenals; but, curiously enough, secondary growths are rarely 
found in the bladder or ureters. 

Etiology. — Most kidney tumors have their origin in embryonal 
tissue, and little or nothing is known of the exciting, causative factors. 
The typical growth found in the kidney during childhood is peculiar 
to children, the majority of cases being seen before the fifth year; 
instances of kidney tumor occurring as early as the seventh month 
of intra-uterine life have been reported, while renal growths after the 
uinth year are exceedingly rare. The left kidney is more frequently 
involved than the right. Both sexes are equally liable to the disease. 

Symptoms. — The three cardinal symptoms of renal tumor are hema- 
turia, pain, and tumor. Constitutional symptoms appear late, and 
not infrequently the first suggestion of a growth is the appearance 
in the lumbar region of a mass which is very soft with smooth or 
irregular surface. It gives rise to no pain, grows rapidly toward the 
median line of the abdomen, and is easily palpable under the large 
bowel. At this time it is so symmetrical that its relation to either 
kidney may* be impossible to ascertain. In some instances, careful 
physical examination is necessary to exclude enlargement of the liver 
or spleen as a cause of the distended abdomen, these organs being 
greatly displaced by the pressure of the invading mass on all of the 
abdominal contents. 

Hematuria is a common, and often an early symptom of the disease, 
indicating an infiltration of the kidney structure by the growth, for 
in purely extrarenal and intracapsular tumors bloody micturition is 
very rare. In the majority of cases, the blood is so scant as to be 
seen only microscopically, although at times the hemorrhage is severe, 
and occasionally so profuse that pain is produced by mechanical 
obstruction of the ureter by clots. 

In addition there may be paroxysmal attacks of severe colic, although 
the pain is usually merely a dull "ache producing discomfort and 
irritability early in thedis ease. A quickly developing cachexia is 
alwavs noticeable; it is unlike that of anemia or tuberculosis, and 



CONGENITAL CYSTIC KIDNEY 557 

is so characteristic of renal tumor as to be regarded as one of the 
cardinal symptoms of this affection. 

Other constitutional signs appear late, and include emaciation, 
loss of strength, digestive disturbances from pressure on the stomach, 
dyspnea from pressure on the lungs, and edema from pressure upon 
the great veins of the abdomen. 

Diagnosis. — This can usually be made with comparative certainty 
when there is a rapidly enlarging tumor mass in the kidney area with 
early emaciation and cachexia, and it is substantiated by the appear- 
ance of blood in the urine. It is clinically impossible to differentiate 
one form of kidney tumor from another; but in view of the fact that 
early operative procedure offers the patient the only chance for 
recovery, the diagnosis of any growth of the kidney should be made 
at the onset of the disease. Kidney tumor should always be con- 
sidered as a possible cause of abdominal enlargement before the sixth 
year; but it must be differentiated from tuberculosis of the kidney, 
hydronephrosis, pyonephrosis, and other tumors of the abdomen, 
such as enlarged liver or spleen, ovarian cyst, and retroperitoneal 
sarcoma. The location of the colon, which runs along and above 
tumors of the kidney, and the position of the swelling near the costal 
margin and projecting into the loin, are of significance in differentiat- 
ing kidney tumor from various abdominal tumors, especially enlarged 
spleen and liver. 

Pro gnosis. —The prognosis is unfavorable, as this disease invariably 
ends fatally except in those cases where an early diagnosis is cleverly 
made, and an operation performed immediately. Even when this 
is done, we have the danger of death from shock during the operation, 
or from metastasis later. 

Treatment. — Medical treatment is of no avail, and is resorted to 
only symptomatically in cases where hope of cure by operation has 
been abandoned because of the extent of the growth or the appearance 
of metastases. Early nephrectomy is justifiable if, by any chance, 
it is thought the child can withstand the operation. A few recoveries 
have resulted where this has been done; and, even if the chance of 
cure be remote, the severity of the symptoms is sometimes greatly 
diminished by surgical intervention. 

CONGENITAL CYSTIC KIDNEY. 

Congenital cystic disease of the kidney is a rare affection. It usually 
affects both kidneys. 

Etiology. — The etiology of these congenital cysts has not yet been 
clearly demonstrated, but Shattuck, after systematic histological study, 
claims that the condition is due to a defect in development, and that 
the mesonephros, or Wolffian body, becomes attached to the kidney 
or melanephros, and the cysts are formed in remnants of the meso- 
nephros embedded in the true kidney. 

The fact that other congenital malformations frequently coexist 



558 



DISEASES OF THE GEN I TO-URINARY SYSTEM 



supports this theory of developmental malformation. The earlier 
view that these are retention cysts due to prenatal nephritis has been 
largely abandoned. Goodhart and Bateman have suggested the term 
" renal adenoma," which implies that these cysts are new growths. 

Pathology. — The cysts vary in size from the diameter of an ordinary 
uriniferous tubule to that of a pigeon's egg, and are most numerous 
in the cortex. In some cases the kidney may become merely a collec- 
tion of tiny cysts, none larger than a cherry, supported by intervening 
atrophied or sclerotic renal tissue, the whole mass weighing a pound 
or more. In other cases the cysts are quite large, some attaining the 
size of a child's head, and they may coalesce. 

Kidney tissue may be wholly absent or, at least, not demonstrable 
in the fatal cases of congenital cystic kidney in children; but in the 
adult some renal tissue is always found. If only one kidney is involved, 
the other kidney compensates for the deficiency of renal tissue in the 
diseased organ. 




Fig. 54. — Congenital cystic kidney in an infant twenty -five days old. 



The cysts contain a clear fluid, which is composed of cholesterin, 
albumin, blood pigment, fat, triple phosphates, degenerating cells, 
and, in rare cases, urea or uric acid. The cyst walls are usually fibrous 
and are lined with flattened or columnar epithelium. There is a dis- 
tinct connective-tissue stroma, and here and there between the cysts 
recognizable glomeruli and urinary tubules with saccular dilatations. 
As a rule, there is no obstruction of the ureters. 

Symptoms. — If there is no other malformation incompatible with life, 
and the kidneys are not so large as to impede labor, the child may be 
born alive; but death usually occurs during delivery or soon after 
birth. In many cases there is a palpable abdominal tumor which may 
cause pressure symptoms. Evidences of renal insufficiency are also 
present. 

Uremic symptoms may occur; but several cases have been reported 




Fig. 55. — Tubular glands resembling sweat glands 



■■.%%$$ 




Fig. 56. — Cyst wall lined by columnar epithelium. 







Fig. 57. — Cyst wall lined by flattened epithelium. 



560 



DISEASES OF THE GEN I TO-URINARY SYSTEM 



of children who lived several months with no renal symptoms. The 
duration of life and the prominence of renal symptoms depend 




frf 



Fig. 58. — Congenital cystic kidney. 



entirely on the amount of normal kidney tissue present. If, as in 
Fig. 54, from which Figs. 55-59 were made, there is little or no 




Fig. 59. — Congenital cystic kidney laid open. 



normal tissue remaining in either kidney, the baby dies within a few 
hours after birth. If only a small amount of kidney substance is 



H YDKONEPHROSIS 51 i 1 

involved, the child may live well into adult life. Where life is pro- 
longed for years, hematuria may appear, also changes in the heart and 
arterial system, similar to those in interstitial nephritis. 

Diagnosis. — The diagnosis of congenital cystic disease is very 
difficult, because there has been little opportunity to study the 
symptomatology. The fact that it is bilateral is an aid in the 
differentiation of this disease from hydronephrosis and malignancy. 

Prognosis. — The prognosis is in many cases unfavorable; but the 
consensus of opinion seems to be that a certain number of cases will 
live well into middle or advanced life, in spite of the disease. It is 
also claimed that the affection may persist for years without producing 
any serious symptoms, or even being suspected. 

Treatment. — Treatment by drugs offers no hope of cure, and surgical 
intervention is rarely justifiable, the condition being usually bilateral. 

HYDRONEPHROSIS. 

Hydronephrosis may be either congenital or acquired, and is not 
a rare condition in children. The congenital form is the more common. 
It makes its appearance during infancy, while the majority of cases 
of acquired hydronephrosis develop late in childhood. One or both 
kidneys may be affected, according to the site of the obstruction, but 
double or bilateral hydronephrosis is so quickly fatal that in many 
instances the tumor is not detected, and the diagnosis is made only 
at autopsy. Acquired hydronephrosis is usually unilateral; therefore, 
more often diagnosed than the congenital form, which is frequently 
bilateral. 

Etiology. — Hydronephrosis is caused by an obstruction to the out- 
flow of urine somewhere along the urinary tract. The congenital 
form results from stenosis of the ureter or urethra, imperforate urethra, 
membranous septa, valves or cysts which impede the flow of urine, 
and to developmental defects of the ureter. The obstruction is gener- 
ally incomplete, for total blocking of the urinary flow tends to produce 
atrophy of the kidney rather than an extreme degree of hydronephrosis, 
although in all types of hydronephrosis the kidney usually shows a 
certain amount of cirrhosis and dilatation. 

Acquired hydronephrosis is most frequently seen as a result of stop- 
page of the urinary flow by renal calculi; but it may also be caused 
by inflammatory stricture of the ureter, pressure on the ureter by 
neighboring tumors, kinking of the ureter, which occurs when the 
kidney is movable, and by a tight phimosis. 

In addition to these two forms of hydronephrosis, Holt describes 
a traumatic hydronephrosis, which develops after the early symptoms 
of trauma have subsided, and results in tumor formation two weeks 
to two months after the injury. The pathology of this condition is 
obscure, but it presents all the characteristics of hydronephrosis aris- 
ing from other causes. The tumor may disappear spontaneously, 
or require surgical intervention for its cure. 
36 



562 DISEASES OF THE GENITO-URINARY SYSTEM 

Pathology. — The kidney is enlarged, often enormously, and loses 
its reniform shape. As the urine accumulates, it first impinges on the 
pelvis of the kidney and then, by pressure, causes dilatation of the kid- 
ney with atrophy of its substance, until in the later stages the organ 
is represented by a palpable fluctuating tumor. This enlargement is 
much slower than the growth of the kidney tumor, and at times may 
considerably decrease in size by the occasional escape of its contents 
past the constriction (intermittent hydronephrosis). 

Some authorities claim that in unilateral hydronephrosis there is 
always a lesion of the opposite kidney, usually a chronic nephritis, 
induced by the nephrotoxic substances which are formed in the blood 
in these cases. Infection of the accumulation of urine in hydronephrosis 
results in pyonephrosis, and consequent general toxemia or septicemia. 
At postmortem, bilateral hydronephrosis has been found to have caused 
dilatation of the bladder in addition to distention of the ureters and 
kidneys. 

Symptoms. — The chief symptom of hydronephrosis is the formation 
of a tumor in the kidney region. When the accumulation becomes 
very large its pressure may produce pain and local tenderness, which 
are relieved by the discharge of a large quantity of urine of low specific 
gravity. As a rule, the urine is scanty in amount, and may not reveal 
any abnormal condition unless infection has taken place in the hydro- 
nephrotic tumor. Bilateral hydronephrosis usually terminates fatally 
in such a short time that no characteristic symptoms appear. 

Prognosis. — Unilateral hydronephrosis offers fair chances of recovery, 
provided that the fluid does not become infected, and the other kidney 
is normal. When both kidneys are involved, the case is invariably 
fatal. 

Treatment. — The treatment of hydronephrosis, whether congenital 
or acquired, is surgical. Exploratory puncture, in addition to giving 
temporary relief, aids in the differentiation of hydronephrosis from 
cysts, new growths, and tuberculosis of the kidney. The ever-present 
danger of infection, and the remote possibility of rupture of the sac, 
seem to justify operation even in the absence of urgent symptoms. 

If a stone is found, or some other obstruction is discovered which 
may be removed, and the kidney is still functionating, nephrectomy 
is by no means indicated ; but if the kidney is infected or practically 
destroyed, and the obstruction cannot be removed, nephrectomy, to 
say the least, prevents secondary nephritis in the other kidney, and 
in many cases saves the life of the child. In view of the fact that 
infection of the accumulated fluid is a common occurrence, the 
administration of hexamethylenamin should be kept up throughout 
the whole course of this disease. 

MOVABLE KIDNEY. 

Movable or floating kidney is a very rare condition during infancy 
and childhood. At this early age it is usually a result of some develop- 



PYELITIS 563 

mental defect, such as an elongated pedicle or a mesonephron, but has 
occasionally been caused by trauma or the pressure of a neighboring 
abdominal tumor. Of the few cases described in literature, the right 
kidney was in children the one most frequently affected. Floating 
kidney was usually associated with dyspepsia and dilatation of the 
stomach, which is probably best explained by the close relation between 
the solar and renal plexuses. 

Other symptoms are few in number. They may consist wholly 
in a slight dragging-down sensation in the kidney region, with some 
tenderness and, perhaps, frequent micturition. In many patients 
there may be no symptoms at all, so that the condition is either dis- 
covered by accident or is brought to the physician's attention when 
the pedicle becomes twisted and causes paroxysms of pain which may 
simulate intestinal or renal colic, or vomiting and intense prostration 
which might cause one to mistake it for appendicitis. Hydronephrosis 
or pyonephrosis may result from obstruction of the ureter, and form 
a tumor in the loins. 

In order to palpate the kidney satisfactorily, the physician should 
stand on the side of the patient corresponding to the kidney he wishes 
to examine, and place his right hand under the left loin, or his left hand 
under the right loin, and allow the child to rest upon it. The opposite 
hand should make gentle pressure upon the front of the same part, 
thus attempting to press the kidney between the two hands. If mov- 
able, it can be felt to slip up toward the liver, or down toward the crest 
of the ilium. Having ascertained that the kidney is movable, and if 
the symptoms are very mild, no treatment is necessary. A belt may 
be worn if discomfort is felt; but operation is only justifiable in those 
cases in which twisting of the ureter causes severe symptoms. 



DISEASES OF THE BLADDER. 



PYELITIS. 

Pyelitis is in reality an inflammation of the mucous membrane 
lining the pelvis of the kidney; but so often is the bladder involved 
as well as the kidney that the terms pyelocystitis, pyelonephritis, 
and pyelonephrosis are, perhaps, more descriptive and accurate as 
applied to the various phases of this affection. 

As a primary disease, pyelitis is probably not as rare as is supposed, 
and were urinalyses made routinely in the case of infants, its existence 
would, perhaps, explain some of the cases of obscure fever at this early 
age. Pyelitis is found secondarily in older children, but it is rare, and 
its manifestations are less striking and typical than in infants. 

Etiology. — The Bacillus coli is by far the most common infecting 
organism in this disease; and while, in a fair proportion of cases, 



564 DISEASES OF THE GEN ITO-UR1 NARY SYSTEM 

staphylococci and streptococci are isolated, other organisms, such as 
the tubercle bacillus, the gonococcus, the Bacillus typhosus, and the 
Bacillus pyocyaneus, are much less frequently met with. 

The bladder is probably always involved primarily in infants, and 
the invading organisms pass up the ureters to the pelves of the kidneys 
giving rise, in the majority of cases, to a bilateral affection of these 
organs, but rarely causing severe inflammation of the bladder. This 
route of infection probably explains satisfactorily the great number of 
little girls affected by this disease, and its relative infrequency in little 
boys, although vulvovaginitis accompanied by pyelitis is rarely seen. 

The numerous cases in which pyelitis in infancy is preceded by diar- 
rhea, constipation, or indigestion, strongly suggest intestinal disturb- 
ance as a preceding factor, and it is quite within reason to assume that, 
in male infants especially, the colon bacillus may gain entrance to the 
bladder directly from the intestines. The majority of cases of pyelitis 
occur in children under two years of age; after the fifth year it is rare, 
is usually caused by renal calculi, and is associated with tuberculosis 
or tumors of the kidney, or is secondary to scarlet fever, diphtheria, 
influenza, or typhoid fever. In exceptional instances there is a history 
of trauma, of suppurative processes in the urethra or vagina, or of the 
ingestion of such drugs as turpentine, cantharides, or carbolic acid. 
Pyelitis is said to be more common in summer than in winter, probably 
owing to the lowered resistance of infants at this season. An enum- 
eration of the etiological factors in pyelitis would scarcely be complete 
without mentioning the hematogenous and lymphogenous routes by 
which the infection may have been carried from some distant part of 
the body. 

Symptoms. — The most characteristic feature of pyelitis in infants 
is the presence of marked constitutional symptoms with little or no 
localized evidence of the disease; while, in older children, the local symp- 
toms are severe and the constitutional disturbances mild. In infants, 
at the onset, there is a sudden and high rise in temperature, not uncom- 
monly preceded by chills and rigors, and accompanied by other evi- 
dences of acute infection, such as vomiting, diarrhea, delirium, or a 
restless drowsiness, and also perhaps a stiffness of the neck and twitch- 
ing of the limbs which suggest meningitis. There is usually little pain; 
but, if it be present, it so closely simulates intestinal colic, as to be 
impossible of differentiation. In some cases the abdominal muscles 
on one or both sides may be rigid. These symptoms are followed in 
a few days by the appearance of mucus or mucopus in the urine, which 
is strongly acid when passed, and, examined microscopically, is seen 
to contain numerous bacilli and pus cells with an occasional cast. 
Fever is usually of intermittent type, ranging from 101° to 105° 
or 106° F. for a week or several days. The chills, however, are seldom 
repeated, although the urine may contain pus for several weeks. 

Older children frequently complain of distinct pain in the abdomen 
with tenderness over the loin; but, as a rule, the disease runs a subacute 
course, with anorexia, nervous irritability, and a variable temperature 



PYELITIS 565 

range. The urine contains pus and desquamated epithelium from the 
various parts of the urinary tract involved. If cystitis also exists to 
a marked degree, dysuria and other bladder symptoms are present; 
and, if pyelonephritis or pyonephrosis develop, there may be evidence 
of tumor formation in the kidney region. Cautley described three 
types of pyelonephritis in children: (1) Acute, with rigors, fever, 
lumbar and abdominal pain, and sweating. The urine is unaffected 
for two or three days, then shows pus and organisms. Sometimes 
there is retention, occasionally blood. (2) Subacute, with unexplained 
fever, anorexia, malaise, anemia, and wasting. (3) Chronic relapsing, 
recurrent attacks with fever, headache, vomiting, malaise, painful 
micturition, and, perhaps, lumbar pain suggestive of stone. 

In the interim, in chronic pyelitis, which is usually due to stone 
or malformations, pyuria may be the only symptom of pyelitis until 
suppurative pyelonephritis or pyonephrosis develops, and causes the 
localized symptoms of pain, tenderness, and swelling. Occasionally, 
perinephritis develops late in the course of the disease; as a rule, it 
rapidly causes an abscess from which the pus is sometimes discharged 
into the pelvis of the kidney, and subsequently voided in the urine. 
Tuberculous pyelitis, when observed, is usually associated with general 
tuberculosis and is evidenced by chronic pyuria and the presence of 
tubercle bacilli in the urine. 

Diagnosis. — Although the diagnosis of pyelitis in infancy hinges 
more on the urinary findings than on any other signs or symptoms, 
the significance of a sudden chill, followed by high fever as being sug- 
gestive of pyelitis, cannot be too greatly emphasized. Typhoid fever, 
acute intestinal indigestion, influenza, and especially malaria, are 
simulated by the mode of onset of pyelitis; but careful study of the 
temperature range, which is intermittent with distinct afebrile periods 
following the discharge of pus, will serve to exclude all of these diseases. 
Other characteristic symptoms of pyelitis are oliguria, pyuria, and a 
variable degree of pain and tenderness over the kidneys. The relatively 
large amount of pus contained therein and the reaction of the urine, 
which is acid, will exclude inflammation of the bladder as the main 
source of the infection, while the severe constitutional symptoms, with 
few or no tube casts or renal epithelium in the urine, are sufficient to 
exclude acute nephritis. Pneumonia, meningitis, and otitis, which 
should always be considered when we have obscure fever in infants, 
may be easily excluded by an accurate history and the absence of signs 
of these diseases upon thorough examination. Very frequently cys- 
titis coexists, and there are symptoms and signs of vesical irritability ; 
also, with the development of pyelonephritis and pyonephrosis, dis- 
tinct lumbar pain with, perhaps, tumor formation which indicates 
that one is dealing with more than simple pyelitis. 

Prognosis. — When pyelitis remains uncomplicated, the prognosis 
is good, and the duration of the disease depends more upon the time 
when it is recognized and treated than upon the nature of the infection. 
In pyelonephritis and pyonephrosis, which usually develop in cases 



566 DISEASES OF THE GENITO-URINARY SYSTEM 

of pyelitis secondary to acute infections, malformations, or tumors of 
the kidneys, the outlook is very serious, so that it is only in cases of 
secondary pyelitis where the primary cause is early recognized, and 
removed before renal involvement takes place, that recovery is to' be 
hoped for. Relapses are not infrequent, and may occur even a year 
after the initial attack. The mortality in uncomplicated pyelitis is 
about 10 per cent. 

Treatment. — The treatment of pyelitis varies with the acuteness 
and severity of the attack, and there can be no doubt that many infan- 
tile cases pass unnoticed and recover spontaneously. The patient 
should be kept at rest in bed, and the diet, which should be bland and 
non-irritating, restricted almost wholly to milk. Water should be taken 
in large quantities, and this may be encouraged in children by flavor- 
ing it with orange or lemon juice. The reaction of the urine should 
be neutralized. For this purpose, hexamethylenamin is largely used 
when hyperacidity is present, one grain every three hours being the 
average dose for an infant one year of age, and correspondingly larger 
doses for older children. 

Citrate of potassium in massive doses is exceedingly beneficial, and 
preferred by many authorities to any other drug for the treatment of 
pyelitis. As much as one-half or even one dram (four grams) may be 
given an infant one year old and upward during the course of a day with 
no decidedly untoward effects aside from slight depression and gastro- 
intestinal disturbance. If nausea, depression, and low temperature 
should ensue, sodium bicarbonate, in 10-grain doses every three 
hours, may be given to an infant under one year of age with splendid 
results and no harmful effects. 

Pain is rarely as intense as in renal colic; but, if severe, may be 
relieved by the local application of heat or cold, or by the administra- 
tion of paregoric, 10 to 15 drops, every two hours until relieved, or 
until four doses are taken, if the infant be a year old or less. 

In chronic cases, the bowels should be watched and regular move- 
ments promoted by adding to the diet enough coarse food to insure 
a large residue, also by the administration of mild cathartics, such as 
compound licorice powder or saline waters. When the diet is greatly 
restricted, as in acute cases, free bowel movements should be obtained 
by the use of magnesium sulphate and enemata. 

In protracted cases of pyelitis, which resist all other treatment, vac- 
cine therapy should be instituted, using the autogenous vaccine when- 
ever possible — for response to this line of treatment may avert the 
development of pyelonephritis or pyonephrosis. When pyelitis is 
secondary, the cause should be removed as quickly as possible, and if 
pyonephrosis develops, surgical intervention is indicated. 

Perinephritic abscess may require merely incision and drainage; 
but if the kidneys be involved, as in suppurative pyelonephritis and 
pyonephrosis, the surgeon must decide upon either nephrectomy, 
nephrotomy, or pyelotomy, according to the extent of renal involve- 
ment and the functional activity of the other kidney. 



CYSTITIS 567 



CYSTITIS. 



Primary cystitis is rare during infancy and childhood, but inflam- 
mation of the bladder secondary to disease elsewhere in the genito- 
urinary tract is not uncommon. 

Etiology. — The organisms most frequently found are the gonococcus 
and the Bacillus coli, which indicates the two sources of infection — 
i. e., the external genitalia and the gastro-intestinal tract. Mechanical 
irritants, such as calculi and gravel, as well as various chemicals and 
medicaments, are also exciting factors, but in only a small proportion 
of the cases. Among the predisposing causes of cystitis are excessive 
cold or heat, strongly ammoniacal urine, trauma, or any condition 
which lowers the tone of the bladder or prevents its complete emptying. 

Cystitis is much more common in girls than in boys owing to the short 
urethra in females, which renders extension of inflammation by this 
path to the bladder quite natural. Phimosis and a narrow urethral 
meatus are two of the causes of cystitis in boys, and, as a rule, the 
affection when due to either of these conditions is very severe. In 
rare instances, tuberculosis or tumors of the bladder may be the cause; 
in some cases, inflammation of the bladder may develop during the 
course of typhoid fever, although bacterium may exist indefinitely 
without giving rise to appreciable bladder lesion. 

Symptoms. — The characteristic symptom of cystitis is pollakiuria 
accompanied by vesical spasm which causes great pain; but in mild 
cases in which there is no pain, the unduly frequent passage of urine 
is often attributed to nervousness, and the cystitis is overlooked. 
In severe cases there are pain and tenderness over the pubes and in 
the perineum, high fever, constitutional disturbance, and even convul- 
sions. The urine is voided a little at a time; it contains epithelium, 
pus, mucus, many bacteria, and a trace of albumin. It is of a reddish 
color, alkaline or slightly acid in reaction, and may show the presence 
of blood, especially if the cystitis is caused by calculi. In chronic 
forms of cystitis the symptoms are less acute and usually exist unrecog- 
nized for an indefinite period until, for some reason, the urine is exam- 
ined. If, however, a vesical calculus be the cause of chronic cystitis 
the symptoms are more severe, and although the pain may not be as 
great as in the acute form, pollakiuria frequently becomes so aggravated 
that the urine appears to be voided continuously. The urine presents 
the same characteristics as in the acute form, and the constant drib- 
bling often gives rise to irritation and inflammation of the genitalia 
and adjacent skin. 

Prognosis. — The prognosis in simple acute cystitis is favorable, and 
prompt recovery may be expected after removal of the cause and 
appropriate treatment. Chronic cystitis may be secondary to some 
primary condition, such as disease of the kidney, tumor, or tubercu- 
losis of the bladder, and in these cases is very resistant to treatment. 

Treatment. — The child with cystitis should be put to bed and the 
diet almost wholly restricted to liquids, milk being, perhaps, the best 



568 DISEASES OF THE GENITO-URINARY SYSTEM 

form of nourishment. The child should be encouraged to drink a large 
amount of water, but other beverages, such as tea and coffee, should 
be prohibited. Potassium citrate in massive doses has proven, in my 
experience, to be the one drug par excellence in cystitis, and as much 
as 1 dram (4 grams) has been administered to an infant a year old. 
The child should take enough of the drug to keep the urine slightly 
alkaline or, at least, neutral in reaction until the pyuria has ceased. 

Urinary antiseptics are also indicated in cystitis, the best results 
being obtained by the use of salol or hexamethylenamin in from 2- 
to 5-grain doses, three times a day, according to the age of the child. 
To relieve the severe pain caused by vesical spasm, atropine sulphate 
may be given in from toVo to ^-q of a grain doses, three times a 
day, according to the tolerance of the child. If this is not efficacious, 
a suppository of opium and belladonna should be inserted in the rec- 
tum, and hot compresses applied over the bladder. Unless the cystitis 
is very severe or shows a tendency to become chronic, irrigation of 
the bladder is not advisable. 

Comparatively few cases of cystitis become chronic during child- 
hood, but when this happens they are very stubborn and require rad- 
ical measures and close supervision to control them Daily irrigation 
of the bladder with a 1 per cent, boric, acid solution, or a 1 to 5000 
solution of either silver nitrate or potassium permanganate, should 
be continued for a week, after which the number of irrigations should 
be diminished each week until recovery ensues, although it is sometimes 
a good plan to use a little stronger solution at each irrigation. 

As yet, the exact value of autogenous vaccines in cystitis has not 
been definitely established, and although satisfactory results have 
been claimed by some observers, my own experience has not led me 
to use them except as a last resort in protracted cases, which have not 
responded to other lines of treatment. 

VESICAL SPASM. 

Spasm of the bladder occurs most frequently in the early years of 
childhood. When observed immediately after birth it is due to uric 
acid infarctions, and later is often caused by an excess of uric acid 
in the urine. It is a characteristic symptom of cystitis and vesical 
calculus, and may be the result of blood-clots, excessive phosphatic 
deposits, or renal gravel which obstructs the urinary flow. Occasion- 
ally, sudden chilling of the lower abdomen or trauma in the region of 
the bladder is followed by vesical spasm, and in rare instances, it is 
seen in association with hysteria, priapism, and masturbation. The 
symptoms are chiefly local, and indicative of great pain and difficulty 
in urinating. In very young children the pain may simulate intestinal 
colic; but the absence of any signs or symptoms of gastro-intestinal 
disturbance, and the distended bladder which abdominal palpation 
reveals, readily establish the source of pain. Urination is frequent, 
but the amount of urine passed each time is small. 



VESICAL CALCULI 560 

Treatment. — Removal of the cause is essential to permanent relief 
of the conditon. Distention of the bladder frequently necessitates 

catheterization; but hot baths or hot compresses applied to the supra- 
pubic region should be tried first in an effort to secure complete evac- 
uation of the bladder. If pain is extremely severe, tincture of hyos- 
cyamus may be given in doses of one to three minims, three times n 
day; or a suppository of powdered opium and extract of belladonna, 
each grain }, may be cautiously used for its relief. 

The child should be encouraged to drink plenty of water, and by 
careful regulation of the diet an effort should be made to prevent hyper- 
acidity or hyperalkalinity of the urine in the future. Potassium citrate 
is, perhaps, the best diuretic in this affection, and may be given to 
advantage through the attack. 

VESICAL CALCULI (URETHRAL CALCULI). 

Calculi in the bladder or urethra of children are only occasionally 
met with. Although, during infancy, the passage of renal sand or 
gravel is quite common, a concretion is rarely of sufficient size to be 
retained within the bladder. The majority of calculi contain uric 
acid and urates, the remainder being mainly oxalates and phosphates. 
The tendency to formation of concretions is greatly increased by any 
inflammatory process along the urinary tract. It has been estimated 
that vesical calculi are twenty times as common in boys as in girls, 
a fact readily explained by the ease with which a stone may escape 
from the bladder through the short and distensible female urethra. 

Symptoms. — The symptoms of vesical calculus are, for the most 
part, associated with the act of micturition. There is great frequency 
of urination, accompanied by pain more or less intense, and referred 
to the end of the penis, to the perineum, or in some cases to the rectum. 
The stream is variable and uncertain, and may be interrupted only 
to be resumed after a change in posture. In some cases there is incon- 
tinence during the day, but rarely during sleep. 

If the calculus be impacted in the urethra there may be a constant 
dribbling of bloody urine and efforts to dislodge it. Straining during 
the act of urination often causes a prolapse of the rectum. When 
violent exercise is taken, pain is usually felt in the bladder region, 
but this quickly subsides upon lying down. If allowed to remain in 
the bladder a stone quickly causes cystitis with characteristic changes 
in the urine; but, in the absence of this condition, the urine usually 
shows an excess of crystals, mucus, a little pus, and/occasionally, blood. 

Diagnosis. — All other causes of vesical irritation must be excluded 
before one is justified in considering it due to a stone in the bladder. 
Once this has been done, the diagnosis may usually be readily con- 
firmed by the .r-ray, the use of the sound, and bimanual examination 
through the rectum. 

Treatment. — Surgical removal of the stone is practically always neces- 
sary; in my opinion, suprapubic lithotomy is preferable to lithoplaxy. 



570 DISEASES OF THE GEN I TO-URINARY SYSTEM 

If the stone is removed before complications have arisen, recovery 
may be expected; but, as a rule, these children are very weak and 
anemic, and should have all the benefits of a carefully regulated, 
nourishing diet, and change of location to seashore or country. 

URETHRITIS. 

Urethritis occurs in both sexes during childhood; but, owing to 
the prevalence of vulvovaginitis with which it is usually associated 
in females, it is far more common in girls than in boys. It may be 
either simple or specific, the simple form being but a slight inflam- 
mation of the anterior portion of the penile urethra caused, generally, 
by lack of cleanliness of the genitalia, and occasionally by injury or 
the passage of uric acid crystals. 

The symptoms are very mild, and consist of a little pain on urination, 
frequent micturition, and a slight discharge of pus which contains 
leukocytes, various microorganisms, and a few epithelial cells. There 
is usually a prompt disappearance of symptoms if the parts are simply 
kept clean. Irrigation is rarely necessary unless the discharge per- 
sists, when the anterior urethra should be gently syringed out daily, 
using a 1 to 2000 potassium permanganate solution, or a 5 per cent, 
solution of argyrol. 

Specific Urethritis. — Gonorrheal infection of the urethra in children 
is much more frequently seen than the simple form, but rarely occurs 
before the sixth year as it is usually contracted through direct con- 
tagion. While not as serious a disease as in adults, gonorrheal urethri- 
tis, in comparison to the simple or non-specific form, is a very severe 
infection, and is not confined to the anterior urethra, but may involve 
the posterior urethra as well, and is not infrequently complicated by 
balanitis, stricture, epididymitis, and inguinal adenitis. 

Orchitis is a rare complication, but though there are few constitu- 
tional symptoms of gonorrhea in the child, arthritis and conjuncti- 
vitis occur not infrequently as complications. The symptoms are 
frequent micturition, accompanied by severe burning pain on urination 
and a profuse, thick, creamy discharge of pus. It is upon the micro- 
scopic examination of this discharge that the diagnosis of specific 
urethritis is based, and there is usually very little difficulty in making 
the diagnosis, for gonococci are, as a rule, present in great numbers. 

Treatment. — Much attention should be paid to prophylactic measures, 
in order that the child's brothers, sisters, and playmates may not be 
contaminated, and also that the child may not infect other parts of 
its own body. The genitalia should be kept securely covered so that 
the child cannot touch the parts, for if the hands become contaminated 
the infection is easily spread. 

The child should be allowed to drink plenty of water, and free 
diuresis should also be promoted by an alkaline diuretic, such as 
hexamethylenamin, which may be given in from 2- to 5-grain 
doses, three times a day, according to the age of the patient. If the 



PHIMOSIS oil 

discharge is pro use, and tends to persist, it is best to irrigate the 
anterior urethra with a 1 to 500 bichloride solution, or a 5 per cent. 

solution of argyrol. 

The diet should be bland and non-irritating, and all spices, seasoned 
foods, beverages, aside from milk and water, should be prohibited. 
The child should eat sparingly and confine the diet to cereals, bread. 
butter, milk, and puddings, with a few vegetables, and little meat. 

Physical exertion, if carried to excess, i> extremely harmful, but 
rest in bed is not necessary. Of great importance is the condition 
of the bowels, and special emphasis should be placed on the fact that 
the patient must have one or two soft stools daily. A properly fitting 
suspensory is often a source of great comfort and a help in retaining 
the dressing while the discharge persist-. 



DISEASES OF THE REPRODUCTIVE ORGANS. 

PHIMOSIS. 

Phimosis is a narrowing of the orifice of the prepuce which prevents 
the withdrawal of the foreskin over the glans penis, and frequently 
results in adhesions between the inner surface of the prepuce and the 
mucous membrane of the glans. Narrowing of the orifice of the pre- 
puce is normal in very young infants, and should be corrected early 
by the mother or nurse, as a tight foreskin retains the smegma, and 
is a constant source of irritation. In time it may interfere with the 
flow of urine, and cause retention, or permit the passage of only a few 
drops at a time, which frequently gives rise to stubborn eczema of 
the genitalia. 

Nocturnal incontinence is often a direct result of phimosis, and in 
rare cases, also of hydronephrosis. The nervous equilibrium of the 
child, as yet undeveloped, is severely deranged by the constant itching 
and irritation. As a result, there is restlessness and peevishness 
during the day, with night terrors and insomnia. In some instances 
it leads to the habit of masturbation, or an attack of hysteria or 
chorea comes on. Adherent prepuce in little girls is not fraught with 
as much danger as the same condition in boys; but it has been claimed 
that, if allowed to persist, the result will be hypererethism or sexual 
apathy in later life. 

Treatment. — In many cases of phimosis, mere stretching of the fore- 
skin and separation of the adhesions will relieve the condition, after 
which the prepuce should be drawn back, and the glans cleansed 
thoroughly every day. Circumcision, while more radical, is, perhaps, 
the best and safest measure with which to secure permanent results. 



572 DISEASES OF THE GENITO-URINARY SYSTEM 



PARAPHIMOSIS. 

Paraphimosis is a condition just the opposite to phimosis, although 
due to the same cause. The narrow foreskin is drawn over the glans 
penis, and forms a tight constricting band behind the corona. The 
glans soon swells, making it impossible to slip the foreskin back again 
over the head of the penis, and if the constriction is not relieved the 
intense edema and failure in circulation will result in gangrene. 

Treatment. — The penis should be bathed in hot or cold water, and 
an attempt then made to relieve the constriction by holding the fore- 
skin between the first two fingers of each hand and exerting pressure 
on the glans with the thumbs while gentle traction is being made on 
the foreskin with the fingers. When the edema is marked, multiple 
punctures of the glans are sometimes necessary to reduce its size. 
If these measures fail, and the circulation is not established, the con- 
stricting band must be promptly incised to prevent permanent injury 
to the glans. 

BALANITIS. 

Balanitis is an acute inflammation of the mucous membrane of the 
glans penis, and is frequently observed in children, its most common 
cause being phimosis. Lack of cleanliness results in the retention 
of smegma and urine between the glans and the prepuce, in conse- 
quence of which the mucous membrane of the glans becomes tender, 
swollen, and covered with pus, and the foreskin edematous and swollen. 
The discharge of pus may be so free as to suggest urethritis. 

Treatment. — Daily cleansing of the parts, followed by an anti- 
septic wash with a saturated solution of boric acid, will usually effect 
a cure within a few days. Circumcision is indicated if the prepuce 
be tight or elongated, but should not be performed until all inflam- 
mation has subsided. 



TORSION OF THE SPERMATIC CORD. 

Torsion of the spermatic cord is a very rare occurrence, and prac- 
tically never happens except in those children where the testicle 
fails to descend or only descends partly. When the testicle becomes 
twisted upon the cord, circulation is cut off because of its constricted 
condition, and gangrene may result if the blood supply is not resumed 
quickly. The symptoms resemble closely those of strangulated hernia, 
and it is also difficult to differentiate this condition from acute orchitis. 

Treatment. — The treatment is surgical and depends upon the length 
of time the circulation has been shut off and the resultant condition 
of the tissues. The cord should be untwisted if possible, and the 
testicle slipped back into place, but if gangrene is present, cord and 
testicle must be excised. 



TUBERCULOUS ORCHITIS 573 



ACUTE ORCHITIS. 

Acute or simple orchitis is rare during childhood, and is usually 
secondary to some systemic infection. The inflammation begins 
in the epididymis. Hydrocele very frequently accompanies acute 
inflammation of the testicles, but has no bearing on the severity of 
the process. 

Etiology. — In children, acute orchitis is seen occasionally following 
urethritis, but a fair proportion of cases occur during the acute infec- 
tions, especially mumps, typhoid fever, and variola. Authorities 
differ as to the prevalence of syphilitic orchitis in infancy and early 
childhood, but from my own observations I should judge it to be rela- 
tively frequent. Injury to the testicles is often followed by a simple, 
mild orchitis; if the trauma be severe, and much damage has been 
done the the tissues, gangrene may set in. 

Symptoms and Pathology. — In simple orchitis the inflammation in 
the epididymis is essentially catarrhal, but when the testicle becomes 
involved the interstitial tissue is invaded, and here the inflammation 
tends to become almost entirely interstitial. The cardinal symptoms 
are pain and swelling, and the size of the scrotum may be increased 
by the presence of a hydrocele, which often accompanies acute orchitis. 
The pain may be felt in the loins, but is most severe in the scrotum, 
which may also be red and edematous. In most instances, in addition 
to the local symptoms, there are systemic symptoms, such as fever, 
anorexia, and malaise. 

Treatment.— The child with acute orchitis should be put to bed and 
kept there until recovery ensues. The testicles must be supported 
by stretching a wide strip of adhesive plaster from the anterior por- 
tion of one thigh to the other, and allowing the scrotum to rest upon 
it. Ice-bags are useful if applied to the scrotum in the very early 
stages of the inflammation; but, after this time, heat is more service- 
able, and should be applied by means of hot compresses renewed 
frequently. 

A saline laxative preceded by a course of calomel, is of great bene- 
fit, and is practically the only internal medication that is of any value. 
The course of the inflammatory process should be watched closely, 
and if suppuration sets in the testicle should be freely incised and 
the pus allowed to escape. The child must wear a suspensory ban- 
dage for several weeks after the attack, for in some instances atrophy 
of the testicle follows acute orchitis. Free circulation of the blood 
should be encouraged in every way possible. 

TUBERCULOUS ORCHITIS. 

There are two forms of tuberculous orchitis occurring in children, 
and it is important that each form should be recognized as such. 
Involvement of the testicles in children with general tuberculosis 
is the most common type, and more rarely is it seen as a part of a 



574 DISEASES OF THE GEN I TO-URINARY SYSTEM 

generalized tuberculosis of the genito-urinary tract alone. Both 
testicles are involved, as a rule, the tuberculous process beginning in 
the epididymis. 

Etiology. — Tuberculous orchitis is a secondary process in almost 
every instance, the infection having been carried to the epididymis 
through the lymphatics, blood stream, or vas deferens. Occasionally 
one may obtain a distinct history of trauma, which has probably 
been an important predisposing factor in determining the testicles 
as a site of the tuberculous lesion. 

Symptoms and Pathology. — The testicle in which a tuberculous pro- 
cess is going on becomes a hard indurated mass as in adults, and if 
the child resists the effects of the systemic infection, which is usually 
present, this mass breaks down, suppuration takes place, the tunica 
vaginalis is involved, the skin ulcerates, and a sinus forms. The cord 
is always thickened. The local symptoms are pain and swelling, for 
in children tuberculous orchitis may be very acute, and a large tumor 
form in a very short period of time. Other symptoms of tuberculosis 
are usually present throughout the body and aid in the diagnosis, 
but even without these additional signs, if tubercle bacilli are found 
in the discharge from the sinus, the diagnosis is established without 
doubt. 

Prognosis. — The prognosis of tuberculous orchitis is much better 
in children than in adults, as the tendency for the process to spread 
and involve the surrounding tissues is much less marked and the 
infection does not assume as serious an aspect. 

Treatment. — The testicles should be treated locally, palliative meas- 
ures at first, such as pressure and the application of iodide of lead 
ointment. Castration should be performed early where the danger 
of general infection of tuberculosis is to be feared, but should not be 
undertaken until the diagnosis is definitely established and suppuration 
is taking place. In every case, whether other lesions of tuberculosis 
are found elsewhere in the body or not, the child should receive the 
benefit of all the hygienic, dietetic, and medicinal measures with which 
tuberculous children are treated. Fresh air is indispensable both night 
and day, the food should be highly nutritious, and the child should 
obtain the proper amount of exercise and rest to materially build up 
the general physical condition. 

TUMORS OF THE TESTICLE. 

Tumors of the testicle are rarely seen during childhood, and, in 
not a few cases where the existence of a neoplasm is suspected, care- 
ful study and investigation will prove the growth to be a tuberculous 
process which has extended from the epididymis. Congenital growths 
are usually malignant, and either carcinomatous or sarcomatous, but 
occasionally one sees a benign growth, an enchondroma or myoma. 
Acquired growths of the testicle are, as a rule, extremely malignant, 
the round-cell sarcoma being the most common. Cystic disease of 



VULVOVAGINITIS 575 

the testicle occurs with relative frequency in childhood, and is always 
a serious problem, since it is impossible to differentiate simple cystic 
disease from sarcoma. 

Symptoms. — Tumors of the testicle are most common from the 
first to the tenth year of life. There are very few symptoms of malig- 
nancy at the onset of the disease, but the tumor grows very rapidly 
in size, and with this increased growth there is a progressive feeling 
of discomfort and weight. The tumor sometimes becomes quite 
large before constitutional symptoms of malignancy and cachexia are 
apparent. 

Treatment. — In view of the fact that most tumors of the testicle 
are malignant, and in those which are not so at the onset there is an 
ever-present possibility of malignancy, a surgical operation for the 
removal of the testicle should always be advised when it is the site 
of a new growth. 

VULVOVAGINITIS. 

Vulvovaginitis is not an uncommon condition in little girls between 
the ages of two and eight years, but rarely occurs in infancy. The 
mucous membrane of the vulva is inflamed and swollen, and the pro- 
cess may extend into the vagina, and, in rare instances, involve the 
urethra and cervix uteri. The majority of cases are not specific, but 
in the poorer classes, especially, gonorrheal vulvovaginitis occurs quite 
frequently. Diphtheritic and aphthous vulvovaginitis are extremely 
rare forms sometimes seen in large institutions. 

Simple Vulvovaginitis. — Simple vulvovaginitis is usually a mild 
catarrhal inflammation, confined for the most part to the vulva, and 
accompanied by a serous discharge; but not infrequently one encounters 
a severe case with intense inflammation of the vulva and vagina, and 
a profuse purulent discharge. The urethral orifice and cervix uteri 
may be involved, and the whole aspect of the case resemble a specific 
infection. Microscopically, the discharge is found to contain numer- 
ous bacilli and cocci, but, while the cocci resemble gonococci in some 
respects, they do not exhibit all the characteristics of this organism. 

Etiology. — Simple vulvovaginitis is caused by uncleanliness in the 
majority of cases, the mucous membrane of the genitalia becoming 
contaminated from collections of smegma, the irritation of decompos- 
ing secretions which have accumulated, or from eczema of the adjacent 
skin surfaces. Occasionally the inflammation is due to the habit of 
masturbation, local injury to the parts (attempted rape, etc.) or to 
scratching in the case of scabies, eczema, or threadworms. 

Delicate and anemic children whose constitutions have been under- 
mined by tuberculosis, malnutrition, poor hygienic surroundings, or 
a recent acute contagious disease, are especially liable to vulvovagin- 
itis, and here we have the probable explanation of the rapidity with 
which an epidemic spreads through the wards of an institution when 
a child with vulvovaginitis is admitted. The exact means of trans- 
mission from one child to another has not been satisfactorilv deter- 



57G DISEASES OF THE GENI TO-URINARY SYSTEM 

mined, but there is no doubt as to the highly contagious nature of 
the discharge. 

Symptoms. — In mild cases, local symptoms of inflammation are 
so slight that the existence of the disease is first brought to notice by 
the appearance of the discharge, which is usually serous and scanty, 
and close inspection of the parts reveals a little redness and swelling 
which, however, are limited to the external genitalia. There may be 
a little local tenderness and a slight itching, intensified on urination. 

Simple vulvovaginitis may be of such a severe type as to present, 
all the characteristics of a gonorrheal infection, and in these cases 
it can only be differentiated by careful and thorough microscopic 
study of the discharge. The labia are red, swollen, and may be ulcer- 
ated; the vagina is inflamed, and the urethral orifice and hymen are 
also involved. The parts are bathed in a profuse, thin, greenish- 
yellow discharge, and urination is attended by much pain. 

If the adjacent skin becomes excoriated walking is painful, and the 
child assumes a straddling gait to prevent friction of the parts. In 
some instances there is a moderate elevation of temperature at the 
onset, but this falls to normal after the acute symptoms have subsided. 

Prognosis. — A mild vulvovaginitis may last two or three weeks, 
but the severe type usually continues for one or two months. Com- 
plications, such as cystitis and urethritis, are rare, and a complete and 
uneventful recovery will follow the institution of proper treatment. 

Treatment. — Vulvovaginitis responds readily to gentle irrigation 
with either saturated boric acid solution, sulphocarbolate of zinc 
solution, or a weak solution of potassium permanganate. The solu- 
tion should be fairly hot (108° F.) and its use should be preceded 
by thorough cleansing of the genitalia and adjacent skin surface with 
soap and water. 

If the labia be excoriated, a soothing antiseptic ointment, contain- 
ing 1 per cent, phenol and 1 per cent, hydrargyri ammoniata, will 
allay the burning sensation and protect the parts from the discharges, 
and a pledget of cotton interposed between the labia will, by keeping 
them separated, prevent friction. In my experience, I have found the 
use of an ointment preferable to dusting powders, which are apt to 
cake when they become moist, and thus cause additional irritation. 

The general health of the majority of these children is poor, and 
improvement in the living conditions, together with the administra- 
tion of a tonic, such as cod-liver oil or the syrup of the iodide of iron, 
will materially hasten recovery. In every case the etiological factor 
should be ascertained and removed, and prophylactic measures 
instituted to prevent the spread of the infection to other children. 

Gonorrheal Vulvovaginitis. — Gonorrheal, or true, vulvovaginitis is 
by no means an uncommon affection in little girls of the poorer classes 
between the ages of two and eight years, since at this age it is not a 
venereal disease, but is contracted accidentally because of close seg- 
gregation. It is one of the most highly contagious diseases met with 
in institutions, and epidemics, once begun, are rarely checked until the 



V UL VO V AGIN I TIS 577 

majority of the female children, if not all of the inmates, are attacked. 
The infection is far more virulent and serious than simple vulvovagin- 
itis, is very resistant to treatment, and, as a rule, runs a protracted course. 

Etiology. — In the majority of cases of vulvovaginitis seen in pri- 
vate practice, it has been contracted accidentally by children sleeping 
with adults, using their towels and toilets, or bathing in the same tub. 
Older children may be contaminated by their playmates manipulating 
the sexual organs, and contamination of the vagina is frequently 
traced to nurse girls, but rarely is vulvovaginitis the result of a 
criminal assault. 

Infants have been known to become infected in their passage through 
the birth canal, but during infancy this disease is usually transmitted 
through the medium of the napkins. 

The exact way in which the contagion spreads in institutions, despite 
strictest prophylaxis and antisepsis, is so obscure that the theory of 
atmospheric infection has been advanced, and although one hesitates 
to accept this, in view of the fact that nurses in charge do not become 
infected, it is only by isolation that the disease is finally eradicated. 
There can be no doubt that the prevalence of the disease is very much 
increased by the poor general condition of health so common in children 
of institutions and the slums. 

Symptoms.— The severity of an attack of vulvovaginitis is extremely 
variable, and while the extent of the inflammation is modified by the 
virulence of the infecting organism and the constitutional condition of 
the patient, records of a large number of cases show that, as a general 
rule, the younger the child, the milder the attack. The inflammation is 
at first severe and the discharge profuse, but in many cases the disease 
is either discovered accidentally during routine examination of chil- 
dren, or the physician is consulted because of the discharge alone, 
other symptoms being so mild as to escape observation. 

The discharge varies greatly and may be largely mucus, muco- 
pus, or a thin, serous, greenish-yellow fluid, but the characteristic 
discharge in gonorrheal vulvovaginitis is a thick, creamy, yellow pus, 
which, when examined under the microscope, is found to contain the 
gonococcus in practically every case and but few other organisms. 
Infants and young children may show no other local sign of inflam- 
mation than a slight hyperemia of the mucous membrane of the vulva 
and orifice of the vagina, with a few crusts on the labia; but in older 
children there is usually redness and swelling of the vulva and vagina, 
and in some instances the skin and mucous membrane become excor- 
iated and even ulcerated. 

The urethra rarely escapes, although the bladder is not frequently 
involved. The cervix uteri becomes inflamed and an endocervicitis 
results, but extension of the process into the internal pelvic organs 
is extremely rare. The inguinal glands are found to be enlarged in 
some cases, and accompanying this there may be a slight elevation 
of temperature which, however, subsides after the acute symptoms 
have passed. 
37 



578 DISEASES OF THE GEN I TO-URINARY SYSTEM 

Irritation of the parts produced by walking causes the child to 
assume a straddling gait which is very much exaggerated if there 
are excoriations of the thighs and labia. Urethral involvement very 
often gives rise to painful micturition, and in every case there is 
increased frequency of urination, which causes nocturnal and diurnal 
enuresis. 

Diagnosis. — A positive diagnosis of gonorrheal vulvovaginitis can 
only be made when gonococci are found in the vaginal smears; and, 
therefore, it is important to obtain a smear in every case of vulvovagin- 
itis, even though the discharge be very scant. In some instances one 
may only be able to state that the cocci present the characteristics 
of the gonococci, and at times cultures must be made before it can 
be positively determined that the organism is the gonococcus; but 
the finding of gram negative intracellular diplococci is accepted as 
conclusive evidence of Nisserian infection. 

Those smears in which we find the gonococcus usually contain few 
other organisms, and so true is this observation that, although the 
gonococcus may not be demonstrated, if very few other organisms 
are found, one should be highly suspicious of specific infection. In 
non-specific or catarrhal vulvovaginitis the discharge is usually com- 
posed of an abundance of several varieties of cocci and bacilli. If the 
facilities are not at hand thoroughly to examine smears and make 
cultures, any case of vulvovaginitis which is accompanied by a profuse, 
purulent discharge should be considered specific, and be treated as such. 

Course and Complications. — Gonorrheal vulvovaginitis runs an 
essentially protracted course; from six to eight weeks is the shortest 
period in which recovery ever occurs, and in most cases three or four 
months or longer are required for its cure. The two complications 
which the practitioner must be warned against are ophthalmia and 
arthritis, for they are seen occasionally and should be recognized and 
treated immediately. Endocarditis, septicemia, and pyemia are rare. 

Prognosis. — Despite its protracted course the ultimate outlook of 
a case of vulvovaginitis in the absence of complications is good. The 
fact that gonococci may remain latent in the genital tract for an almost 
indefinite period should not be overlooked, however, as this is no doubt 
responsible for the numerous relapses which occur. 

Prophylaxis. — The extremely infectious nature of gonorrheal vulvo- 
vaginitis makes the consideration of prophylactic measures of utmost 
importance. In the home, if one child is affected, it should be isolated 
from the others in so far as this is possible, and at least all relations 
or associations with other children should be avoided. This refers 
particularly to the child's clothing, bed linen, towels and table silver, 
which should be kept apart at all times from those of the rest of the 
family. 

The child should bathe in a tub which no one else is allowed to use, 
should use a separate toilet, and should wear pads which are changed 
frequently and the soiled ones burned. Too much attention cannot 
be directed to the necessity of absolute cleanliness, and this is espe- 



VULVOVAGINITIS 579 

cially important with regard to the hands, which, if soiled, may easily 
be the means of conveying the disease to other children. 

Prophylactic measures must be carried out to even a greater degree 
if epidemics are to be avoided in institutions where children are con- 
gregated together. Every applicant for admission should be thoroughly 
examined for vaginal discharge, and even if the microscopic exam- 
ination of a discharge be negative, the patient should be isolated for 
at least two weeks and repeated examinations made, for in a large 
number of cases where thorough study of the discharge is made one 
is able eventually to demonstrate the gonococcus. 

The routine examination of all children in institutions twice or 
three times a week is recommended as the only means to eradicate 
the disease. Children isolated because of a discharge should be under 
the care of special nurses; for it is practically impossible for a nurse 
to attend a child with vulvovaginitis without conveying the disease to 
other children. Care must be taken to disinfect all linen and clothing 
before allowing it to go to the general laundry, and all pads and 
dressings should be burned. 

A nurse treating more than one case of vulvovaginitis should care- 
fully cleanse and disinfect her hands after attending each patient, 
and should see that the toilets and tubs are disinfected each time they 
are used in order to prevent reinfection of convalescent patients. 
It is unwise to allow any patient to mingle with other children until 
there is absolutely no vaginal discharge remaining, for in many 
instances fresh outbreaks of vulvovaginitis have followed where 
children have been taken out of quarantine, simply because there 
were no gonococci demonstrable in the vaginal secretions. 

Treatment. — Cleanliness of the parts is the prime essential in the 
successful treatment of gonorrheal vulvovaginitis, and this is mainly 
secured by means of douching and flushing the vagina. In the initial 
stage, when the inflammation is severe, a vaginal douche should be 
given three or four times daily, using at least two quarts of either a 
1 to 5000 potassium permanganate, or 1 to 5000 bichloride solution, 
the temperature of which should be about 106° to 108° F. 

The use of various other irrigating fluids, such as normal saline, 
boric acid, and silver salts solutions will, perhaps, be found to give 
equally good results, since the real benefit of the douche is apparently 
due to its cleansing effect more than to anything else. The female 
catheter is undoubtedly the best irrigating nozzle for this purpose, 
but care should be taken not to insert it too far or injure the parts 
in any way, or force the solution into the uterine cavity by allowing 
the stream to flow too swiftly. 

If the child be under the care of inexperienced persons it is some- 
times wiser to omit douching, and simply allow the child to sit in 
a large basin partly filled with warm boric acid or saline solution, 
several times a day. In addition to this the vagina may be packed 
with cotton saturated with weak solutions of potassium permanganate, 
bichloride, or one of the various silver salts. 



580 DISEASES OF THE GEN I TO-URINARY SYSTEM 

Strong applications, such as 2 to 5 per cent, silver nitrate or pro- 
targol solutions, or 10 to 20 per cent, solutions of argyrol, are often 
used advantageouly after irrigating, and may be either daubed on 
with a swab or instilled in small quantities into the vagina. A vulvar 
pad should be worn constantly, and changed as frequently as the 
amount of discharge necessitates, and whenever the underclothing is 
soiled, fresh linen should be put on lest the child be reinfected by the 
soiled garments. 

Care should be taken that the child's hands do not become con- 
taminated, and the danger of infecting the eyes should be explained 
to the nurses and attendants, who should be instructed to burn all 
pads and dressings and disinfect all soiled clothing before having it 
laundered. At the best, recovery is a slow and tedious process, and 
relapses are common; and if a case is unusually protracted vaccine 
treatment is sometimes resorted to with excellent results. 

Stock vaccines are quite as effective as autogenous, and the dose 
should be gradually increased from an initial injection of fifty million 
up to one or two hundred million within a week. If the facilities are 
at hand it is always advisable to determine the opsonic index before 
and after a dose of the vaccine, in order to calculate the exact effect 
of the treatment; although no untoward effects have ever followed 
the administration of these vaccines in this manner. 

Because of the poor general health of these children, they improve 
much more quickly if, in addition to local treatment, they are removed 
to the seashore or country, and given a good nutritious diet. The 
general constitutional condition should be built up by the adminis- 
tration of tonics such as the syrup of ferrous iodide, or cod-liver oil. 

GANGRENE OF THE VULVA. 

Gangrene of the vulva, or noma vulva?, is a condition analogous 
to cancrum oris, and differs from that disease only as to the site of 
the lesion. It usually occurs in greatly debilitated children, following 
one of the acute infections, commonly measles or diphtheria, or may 
arise during the course of enteric fever or dysentery. It never occurs 
primarily except where great injury has been done to the parts, as 
in severe crushing or by the continued application of strong alkalies 
or acids. 

A swelling of one of the labia is usually the first symptom of 
approaching gangrene, after which the part becomes indurated and 
finally breaks down, forming a foul-smelling, sloughing ulcer, which 
spreads rapidly, invading the surrounding tissues. The prognosis 
is nearly always hopeless, because of the already weakened condition 
of the patient, and the rapidity with which the gangrene spreads 
through the devitalized tissues, and affects the whole constitution 
by the absorption of toxins. 

Treatment. — Wide excision offers the best chance of checking the 
disease, but is not always possible because of the close proximity 



MENSTRUATION PRECOX 581 

of important structures. Cauterization is sometimes followed by 
diminution in the severity of the gangrenous process, and may enable 

the physician to get it under control. The parts should be cleansed 
ever so often, and the child's strength should be supported by an 
abundance of nourishing food and stimulants at frequent intervals. 

VICARIOUS MENSTRUATION. 

Vicarious menstruation is exceedingly rare in children, but occurs 
with sufficient frequency to demand recognition. The cause is 
unknown. In many instances there is precocious development of 
the genitalia or of the whole body, and, although vicarious menstru- 
ation, in itself, is not particularly harmful unless the hemorrhage is 
severe, the resultant anemia from, for example, a periodical epistaxis 
every three or four weeks, lasting for from two to five days, would be 
quite serious in delicate,- tubercular, or syphilitic children. 

Treatment. — There is no known treatment which has any influence 
on the occurrence of the hemorrhages of vicarious menstruation, there- 
fore attention should be directed to keeping up the child's nutrition 
and combating the anemia. The diet should be carefully regulated, 
so that the amount of nutrition received is the maximum, with a 
minimum effect on the gastrointestinal tract. 

Iron is, perhaps, the one best drug for these children, and may be 
given as the syrup of ferrous iodide in 10-drop doses, three times a 
day, to a child of five years, or one of the various easily assimilable 
preparations of iron may be included in a tonic mixture. Where 
the opportunity presents itself, these children should spend a few- 
months each year at the seashore or in the mountains. 

MENSTRUATION PRECOX. 

Menstruation precox is very rare in early childhood, but it is 
not an uncommon occurrence in the United States for girls of eight 
and ten years to menstruate regularly. In these latter instances, 
the subjects are either very strong and healthy or very delicate, 
but very young children who menstruate are usually overdeveloped, 
mentally and bodily. 

Many of the delicate children who menstruate too early have 
syphilis or tuberculosis, which may be responsible indirectly for the 
condition, because of its effect on the constitution. 

Symptoms. — As in adults, the periods may last from one to five days, 
but they are much more irregular as to the time of their occurrence, 
and in some instances, after one or two periods, menstruation will 
cease till puberty. During the periods the symptoms resemble those 
in adult life, and the child is restless, nervous, and has colicky pains 
in the abdomen, slight fever, swelling of the mammae, shows a change 
of disposition, and even a certain amount of sexual excitement. 

AYhen the period is missed there are also sensations of discomfort 



582 DISEASES OF THE GEN I TO-URINARY SYSTEM 

and other signs like those in the adult. Before one may definitely 
state that a given case is one of menstruation precox, bleeding from 
the genitalia from other causes, such as masturbation and severe 
vaginitis, must be excluded, and the periodicity of the vaginal discharge 
of blood must be definitely established. 

Treatment. — A child who menstruates several years before it should 
normally had better be kept in bed during each period. An ice- 
bag sometimes gives relief to pain if placed over the uterus, but cool- 
ing drinks are apt to cause pain, while warm liquids are often very 
soothing. 

If bleeding be profuse, the fluidextract of ergot may be given 
in 10-drop doses three times a day to a child of five years; stypticin, 
grain i to f three times a day, may be used, the dose of this drug 
varying according to the age of the child and degree of hemorrhage; 
hydrastin may be given in the form of hydrastin hydrochlorate, in 
doses of from 2V ^° To" °f a grain. 

MASTURBATION. 

Masturbation is not an uncommon practice during childhood and 
is also seen quite frequently during infancy, although rarely before 
the first year. In older children this practice is much more common 
in boys, but from my observations of this condition in infancy I 
believe that it occurs in female infants much more frequently than in 
males. Thigh rubbing, and not manual manipulation of the genitalia, 
is invariably the method of exciting the orgasm in infantile mastur- 
bation, and for this reason it has been regarded as pseudomasturbation 
by some authors. 

Etiology. — Thigh friction during infancy is usually begun because 
of some irritation of the genitalia or buttocks, which has induced 
rubbing of the parts to allay the itching. Lack of cleanliness of the 
thighs, buttocks, and genitalia is, perhaps, the most important factor 
which incites the habit of masturbation, for, as a result of accumu- 
lations of secretions and excretions, a balanitis or vulvitis of a mild 
degree exists, which is often the exciting cause. Seatworms, highly 
acid urine, eczema of the adjacent skin, and even too tight clothing 
are many times responsible for the habit. 

There can be no doubt that the general physical condition of these 
children plays an important part in determining the establishment 
of the act of masturbation, and in many cases one may obtain a 
definite history of inherited neurotic tendencies, which have been 
fostered and aggravated by the child's environment and lack of care. 

In rare instances it occurs in children where no local or general 
cause can be found, and under these circumstances one should always 
suspect and look for other signs of mental deficiency. In children 
of seven years and over who masturbate we must consider other 
factors which are in no way related to this habit during infancy, for 
at this age not uncommonly true sexual feeling is incorporated in 



MASTURBATION 583 

the act, especially when it has developed because of surroundings of 
immorality. 

I am convinced that in but few cases of masturbation in older 
children has the habit been contracted accidentally, as in washing 
the genitalia, scratching to allay irritation, or in climbing; and that 
imitation of the a.ct by younger children who see their more mature 
playmates perform it, and initiation of children to this habit by 
nurse girls and attendants, are its two most frequent causes at this age. 

Symptoms. — Infants usually masturbate by holding the thighs 
close together and moving the whole body so as to produce friction; 
sometimes an infant will be seen to perform a series of backward 
and forward and side-to-side movements while lying on the back, and 
still others lie on the abdomen and rub the genitalia on a pillow or 
the bed. 

The variety of methods adopted is endless, but in each case the effect 
produced is the same; the child's exertions become more marked with 
each movement and nervous excitation increases, the face becomes 
flushed and covered with perspiration; at the height of the act a few 
grunts may be emitted, after which the movements cease and the 
child falls back exhausted and pallid. 

Rarely are any ill-effects noticeable in infants addicted to masturba- 
tion, although the already unstable condition of the nervous system 
is no doubt aggravated by the frequent excitation and stimulation. 

The local symptoms are vague and insignificant. There may be 
noticed on close inspection a slight redness of the parts, and the pre- 
puce or the nymphae may be swollen. 

The occurrence of frequent erections is a very suggest ive sign 
of masturbation and I have found this symptom fairly constant in 
a number of the cases under my observation. After the fifth year 
the habit is usually practised manually, and these children often 
exhibit the so-called "tell-tale" signs of masturbation, such as sunken 
eyes, with dilated pupils and dark rings around them, palpitation 
of the heart, headache, and constant fatigue, but in most instances 
these are merely symptoms of neurasthenia. 

When practised persistently, and to great excess after infancy, 
masturbation is highly suggestive of imbecility, or at least a certain 
amount of mental deficiency, and in these cases the child's physical 
condition may become greatly impaired; but too many dire effects 
have been attributed as results of this habit, for if carried on to a 
mild degree, unless one catches the child in the act, it may escape 
the notice of both parents and physician, so slight are the signs and 
symptoms. 

These children are usually languid and shy to a greater or lesser 
extent, showing little or no disposition to play the usual games of 
childhood, and are often backward in school, peevish, and irritable, 
By far the greatest harm done by masturbation is the effect on the 
moral nature of the child who practises it and is conscious of wrong- 
doing, for from then on it is the mind which suffers and not the body. 



584 DISEASES OF THE GEN I TO-URINARY SYSTEM 

Moral degeneration in one child just at the imitative age also 
results quickly in spreading the habit, and the harmful effects on his 
or her associates are far-reaching and unlimited. As soon as the child 
who masturbates comes to the realization that the act is wrong, it 
naturally practises it in secret, which produces that air of seclusive- 
ness and the guilty expression so characteristic of the masturbator. 

Prognosis. — The prognosis is favorable, but the duration of the habit 
depends greatly on the age of the child, and to a lesser extent upon 
the length of time it has been practised, and upon the child's mental 
and physical condition. In infancy spontaneous recovery usually 
takes place before the second year, but the duration of the habit 
may be appreciably shortened by appropriate treatment. Older 
children are not so amenable to treatment and some of these cases 
are most obstinate and persistent in spite of rigid discipline and 
thorough care, but unless great mental deficiency or imbecility is to 
be reckoned with, no case should be regarded as intractable. 

Treatment. — Prophylaxis with regard to masturbation is very 
important, for prevention of the habit is far easier than the cure. 
Of prime importance is careful attention to cleanliness of the genitalia 
and avoidance of all sources of irritation to the parts. Male infants 
should have the glans exposed and cleansed each day at the time the 
bath is given, and if phimosis is present, or the prepuce is greatly 
elongated, circumcision is advisable. 

In little girls the same amount of care and attention is required 
to prevent irritation around the clitoris. Older children should be 
trained never to touch the genitalia and should be carefully watched 
to see that these instructions are carried out. Masturbation is usually 
practised just after the child is put to bed, or before arising in the 
morning, and if the parents are told this they may be able to restrain 
the habit to a great extent themselves, by not allowing to child to 
lie awake alone before it goes to sleep or just after it awakens. 

Children must never be allowed to sleep together when visiting 
each other, and even within the family circle the juvenile members 
should each have a separate bed wherever possible. Parents should 
investigate carefully the morals of their children's playmates, and 
when children attain the age of reason and understanding, explain 
to them the whole subject of sex hygiene rather than have them 
accept the perverted and misconstrued conception of these matters 
which they are sure to learn from their associates. 

When the habit is once established in infancy there are two lines 
of procedure which must be followed out in order to break it up — 
removal of the cause, and forcible restraint to interrupt the practice 
immediately. In many instances removal of the cause is sufficient 
in itself to effect a cure, but the child should be watched closely for 
some time afterward and any suspicious movements should be 
discouraged. The method of restraining the infant from mastur- 
bation depends, of course, upon the particular way in which the 
act is performed. 



MASTURBATION 585 

If possible, a nurse should be detailed upon each ease to watch 
the child continually and forcibly prevent the accomplishment of 
the act by taking the child up out of bed and holding it each time 
the movements begin. Since it is very inconvenient and often 
impossible to have a child under direct observation for twenty-four 
hours each day, mechanical appliances are employed, which many 
times are practical and of great service. These appliances may be 
improvised at home or purchased from any surgical instrument maker, 
and for the most part comprise triangular splints which are placed 
between the legs and adjusted so that the base of the triangle keeps 
the knees apart, thus preventing thigh friction, and knee braces 
have also been devised for the same purpose. 

I have many times obtained excellent results by instructing the 
nurse to fasten one foot to one corner of the crib and the other foot 
to the opposite corner and keep the thighs separated in this manner. 
If manual masturbation is practised, the hands may be incapacitated 
by having the child wear a sleeveless gown or tying each hand to 
opposite sides of the crib. 

In older children, forcible restraint is a much more difficult matter, 
and if punishment is given for each offense there quickly develops 
a tendency to perform the act in secret which renders these cases 
all the more difficult to treat. Moral suasion is often very effectual 
where secret indulgence is practised, if the patient's confidence is 
gained. Those in attendance upon such a case should employ the 
most tactful and diplomatic methods, thereby impressing the patient 
with their desire to help in breaking the habit rather than to accuse 
him of a shameful practice continually. 

Moral cleanliness should be pointed out to these children as a virtue 
to be sought for and attained, and an attempt should be made to 
substitute healthy outdoor sports for the lewd, sexual excitement 
aroused in the mind of a child who is the victim of the habit. 

I have rarely seen these children benefited by the administration of 
drugs and do not advise their use, since the amount of any drug 
sufficient to inhibit the act is often so great as to make the child 
stuporous. In infancy, however, the administration three times a day 
of bromide of s.odium in 2-grain doses, or tincture of belladonna in 
1-drop doses, will sometimes quiet the patient and aid materially in 
the general treatment of the case. The child who masturbates should 
be treated physically as well as trained mentally. 

A change of climate, associations, playmates, nurses, and environ- 
ment is of tremendous advantage when possible, since it supplies 
new material for the child's attention and engages his interest so 
completely that the habit may be unconsciously neglected. The 
diet should be carefully regulated so that an increased amount of 
nutrition is afforded without undue tax upon the digestive system. 
Medicinal tonics such as arsenic, cod-liver oil, or various preparations 
of iron are undoubtedly of value, but may be disregarded entirely 
in treatment if cold bathing and plenty of outdoor exercise are 
indulged in. 



CHAPTER XX. 
DISEASES OF THE SKIN. 

In no other organ of the body is a healthful condition during childhood 
of greater importance than in the skin, which is intimately concerned 
in two vital processes — excretion and heat radiation. While the 
proper functionating of the skin is so highly necessary to the child, 
yet the skin is at the same time extremely tender and delicate, therefore 
much more susceptible to disease than in the adult. It is very sensitive 
in its response to systemic conditions, and normal, healthy skin in an 
infant is an indication of the efficiency of the other vital functions of 
the body. 

Infection of an infant's skin may occur without any appreciable 
break in its continuity; mere stretching will traumatize it. Neglect 
of the skin, especially during infancy, is quickly followed by inflamma- 
tion and infection. Clothing, if excessive, will cause sudamina, and 
even eczema. Flannel and wool are irritating, and should not be 
worn next to the skin. Excretions, such as sweat, urine, and feces, if 
allowed to remain in contact with the skin, quickly give rise to inflam- 
mation, therefore special attention should be given to the cleanliness 
of the infant. Bathing very young children, at least twice daily, is 
necessary to secure the proper function and healthy condition of the 
skin. 

The common lesions of the skin during childhood are lichen, eczema, 
impetigo, ecthyma, furuncular eruptions, herpes, and erythema. Less 
frequently we see psoriasis, tinea, alopecia, and molluscum contagio- 
sum. Occasionally, cases of pemphigus, keloid, and erysipelas are 
observed. In infancy, congenital disorders, nevi, ichthyosis, sclerema 
neonatorum, eczema, and, particularly, pustular infections appear. 
At puberty, acne, seborrheic dermatitis, and other disturbances of 
the sebaceous glands occur. Inflammations of the skin, because of its 
delicate structure, are, in younger children, usually acute in type. 

ECZEMA. 

The usual types of eczema in children are the vesicular and pustular 
forms, or a combination of the two. Although eczema is of an acute 
type, its course is frequently chronic, and it may last several years. 

Etiology. — The most common causes of eczema in infants and young 
children are soap, hard water, rough clothing, and pathological secre- 
tions. The presence of toxins in the blood, due to deficient elimination, 
imperfect metabolism and assimilation of food, caused by improper 



ECZEMA 587 

or irregular feeding, are important systemic causes. Local infection 
of the skin by pyogenic organisms is more common during childhood 
than at any other time of life, and may produce eczema. 

In children eczema most frequently involves the face, head, ears, 
the creases of the neck, axilla, groin, scrotal, and anal regions. It is 
often associated with scabies and pediculi, as rubbing and scratching 
because of itching from any cause may give rise to eczema. More 
than one-third of the cases of eczema seen in children occur during the 
first year, and most of these before the fifth month. 

Symptoms. — Itching is the chief subjective symptom, and the one 
most difficult to relieve. The scratching which follows results in the 
rapid spread of the disease and the formation of thick crusts composed 
of blood and pus. The skin surrounding the encrusted area is reddened, 
thickened, and inflamed, with scaling at the margins. 

In children pediculi are associated with eczema of the scalp more 
frequently than in infants, and they tend to aggravate the condition 
by increasing the severity of the itching. 

Diagnosis. — The diagnosis of typical cases of eczema, in children is 
easy, but it must be differentiated from erysipelas, scabies, psoriasis, 
impetigo, and syphilis. Erysipelas is distinguished by its rapidly 
spreading margin and by the high fever which accompanies it. 

Scabies may occur with eczema, but should not be confused with it, 
the distribution being different. The itching is worse at night. The 
parasites may be demonstrated in scabies, and there is usually a. history 
of scabies in other members of the family. 

Psoriasis is essentially dry, while the eczema of children is usually 
moist. The elbows and knees and extensor surfaces are affected in 
psoriasis, while the flexor surfaces are the usual sites of eczema. The 
silvery scales of psoriasis are characteristic, and can be demonstrated. 

Syphilides show no tendency to itch, and the lesions are not as 
acutely inflammatory as in eczema. There are usually other symptoms 
and signs of syphilis in the infant or child. 

Treatment. — Success in the treatment of eczema is only attained 
after a thorough search for, and removal of the cause, and the persistent 
application of measures to relieve the condition. Regulation of the 
diet is, perhaps, the most important factor in treatment. The bowels 
should be thoroughly cleaned out, and thereafter kept regular. Alka- 
line diuretics are also indicated to relieve the hyperacidity of the urine. 

Aside from these general measures, there is no internal medication 
of specific value. Local treatment is directed to the relief of itching 
and the prevention of scratching. If the eczema be of a mild degree, a 
dusting powder of zinc stearate, zinc oxide, or boric acid may be used 
after thorough cleansing of the skin, which, however, should never be 
attained by the use of soap. When water is used, it should preferably 
be boiled first, and should contain boric acid or a solution of bran. 

In more severe cases, boric acid ointment (1 dram to the ounce of 
petrolatum) may be daubed on the eczematous area with a piece 
of cotton instead of cleansing the part with water. For the relief of 



588 DISEASES OF THE SKIN 

itching, phenol may be added, using 5 grains to the ounce of ointment. 
Lotions containing zinc oxide and lime-water, or calamine lotions, are 
very soothing and beneficial. In cases with much moisture, a solution 
of silver nitrate, one-half of 1 per cent., may be used to advantage. 

Subacute eczemas in children are apt to appear after infancy, and 
call for mild stimulation with an ointment containing resorcin, zinc 
oxide, and bismuth. In chronic cases, stimulation should be somewhat 
stronger, and for this sulphur, resorcin, creosote ointment, Lassar 
paste, or tar ointment is advisable. 

All dressings must be firmly secured, and in infants and young 
children, especially, this is very difficult. In eczema of the face and 
scalp, a mask which fits well down over the neck is excellent, as it not 
only insures the continuous application of the ointment, but prevents 
scratching. A good plan for preventing scratching of any affected 
part is to put a straight splint on each arm, thus making flexion of 
the elbow impossible. 

When eczema of the scalp is complicated by pediculosis, as is fre- 
quently the case, the crusts resulting from persistent scratching are 
very hard and thick, and must be removed before the application of 
ointments, but must be removed carefully, or the condition will be 
aggravated. The best method is to apply olive or cod-liver oil, con- 
taining 1 dram of phenol and 2 drams of balsam of Peru to the ounce. 
After several hours of soaking, the crust may be easily taken off 
with the aid of warm water, and this should be followed by the applica- 
tion of the ointment or lotion desired. The scalp should be treated 
with petroleum, bichloride solution, or alcohol for the removal of 
nits and pediculi. 

The following prescriptions have been employed with excellent 
results : 

Acute Eczema. 

]$ — Phenolis ' gr. v 

Calaminae • • 3.i 

Ung. zinci oxidi 3vij — M. 

Subacute Eczema. 

1$ — Acidi salicylic) gr. xx 

Pulv. amyli, 

Pulv. zinci oxidi aa 3*i 

Petrolati 3iv — M. 

Chroncc Eczema. 

fy — Ung. picis liquidse 3J 

Pulv. zinci oxidi 3ij 

Ung. aquae rosse 3iv — M. 



URTICARIA (NETTLE RASH: HIVES). 

Urticaria in children differs slightly from the form seen in adults. 
It is characterized by a multiform eruption of whitish, pinkish, or 
reddish color, which suddenly appears, and as suddenly disappears, 
showing a marked tendency to recurrence. This eruption is accom- 



ICHTHYOSIS 589 

panied by painful, pricking, and tingling sensations. Papules are 
most abundant in those forms in which the attacks last for weeks, 
while wheals appear in those of short duration. In severe cases, 
there may be vesicles, vesicopustules, and pustules. The eruption is 
most intense on the trunk; but the lesions shift about, and when 
they appear on the face may be quite disfiguring. 

Etiology. — So frequently is gastro-intestinal disorder a cause of 
urticaria that the latter is now considered to be a cutaneous mani- 
festation of toxemia caused by faulty digestion and metabolism. 
The mere presence of indigestible food in the stomach of an infant 
may cause urticaria, and certain cases may be traced to intestinal 
parasites. Sea food, canned meats and vegetables, pastry, confec- 
tioner}', and certain fruits, particularly berries, are liable to cause 
urticaria. 

A few cases may be traced to the bites of insects, giving rise to a 
localized area of urticaria which quickly spreads. Sudden emotion or 
excitement may bring on an attack in a susceptible child. Certain 
drugs, among which are quinin, arsenic, the salicylates, and opium, 
also the serums, will produce urticaria in some individuals. 

Symptoms. — The local symptoms are the severe burning and intense 
itching which accompany the eruption. In children, an urticarial 
attack may often be preceded by gastric and nervous disturbances and 
a rise in temperature. 

Diagnosis. — The diagnosis is easy, and is sometimes made by the 
parents. The rapidity of the onset and appearance of the eruption, 
and the severe itching which accompanies it, leave little doubt as to 
the affection. Usually there is a history of preceding attacks. 

Treatment. — The chief considerations in treatment are restriction 
of the diet and regulation of the feeding. An initial purge is followed 
by light diet, free from all irritating foods. Alkaline waters internally 
and alkaline baths are very beneficial. 

The administration of codein is sometimes necessary to quiet the 
nervousness produced by the itching. The skin may be sponged 
with a lotion containing from 0.5 to 1 per cent, of either phenol, 
dilute hydrocyanic acid, or menthol. Instant relief may often be 
obtained by the use of the prescription below: 

1$ — Phenolis 5iJ 

Glycerinae foj 

Aquae . . . q. s. f §xvj — M. 

Sig. — Use as a spray. 

ICHTHYOSIS. 

Ichthyosis is a congenital disease of the skin characterized by a 
hardness and dryness, also by a scaliness from which it gets its name 
of fish-skin disease. In some cases the skin is much thickened and 
furrowed, and resembles a suit of armor. This severe degree of 
ichthyosis is rarely seen; the children who are born with the disease 
so well developed are generally monsters, and do not live. In the 
common type, ichthyosis is not incompatible with life. 



590 DISEASES OF THE SKIN 

Etiology. — The cause of ichthyosis is unknown. 

Symptoms. — The ordinary type of ichthyosis usually appears during 
the second year. The skin becomes dry, wrinkled, papery, and 
scaly. The whole body may be involved, but the disease is more 
severe on the outer surface of the arms and legs, the general health 
remaining unaffected. 

Diagnosis. — Ichthyosis has such typical characteristics that it is 
rarely mistaken for any other affection of the skin, the absence of 
inflammation being, perhaps, its most distinctive feature. 

Prognosis. — There is no cure for the disease, and in authentic cases 
no recoveries have ever been reported. The condition of the skin 
may greatly improve under careful, proper, and persistent treatment. 

Treatment. — Children with ichthyosis are greatly benefited by res- 
idence in a moist, warm climate, and this should always be strongly 
advised. Frequent bathing in alkaline waters, followed by the appli- 
cation of an oily substance, will prevent the skin from, becoming 
extremely dry and rough. Almond oil, cod-liver oil, cottonseed or 
olive oil may be used, and to any one of these may be added salicylic 
acid or resorcin. No internal medication seems to be of much value, 
although thyroid extract is recommended by various authorities. An 
ointment to keep the skin moist and smooth may be prescribed as 
follows : 

1\ — Acidi salicylici '. . . gr. xv 

Glycerinse ITlxxx 

Lanolin 5'j 

Resorcin gr. xl 

Adipis benzoate 5vj 

Ung. paraffin 3 i J — M. 

INTERTRIGO. 

Intertrigo is a very common disease during childhood, especially 
in infants. It is a chafing and rubbing off of the superficial skin, 
which has been macerated by constant moisture of the parts. It 
occurs in the natural folds of the skin, and is most frequently seen 
on the buttocks and scrotum, in the groin, and axilla. 

Etiology. — Maceration of the skin which precedes the chafing is 
caused by the action of highly acid urine, feces, or even perspiration. 
Intertrigo may be found in any parts of the body where two skin 
surfaces rub against each other during movement. The superficial 
epidermis comes away as a result of this chafing and leaves a moist, red 
surface, which soon becomes infected. 

Symptoms. —The lesions vary in degree from mere erythema to an 
encrusted area of infected skin, which is actively inflamed, painful, 
and tender. There are usually no constitutional symptoms, the 
cause being local. 

Diagnosis. — The diagnosis is easy, the only other skin lesion simu- 
lating it closely being cutaneous syphilides in the natural folds of the 
body. In a given case, however, this syphilitic eruption will usually 



IMPETIGO CONTAGIOSA 591 

be found in other locations and concomitant symptoms, such as 
snuffles or hoarseness, may be present. A Wassermann reaction will 
aid materially in a doubtful case. 

Treatment. — Prophylaxis is very important and also practical in 
intertrigo. Strict cleanliness must be maintained without the too 
frequent use of soap. The buttocks should be sponged off with warm 
water after each evacuation of the bowels, and the napkins should 
always be fresh and clean. The urine may be highly acid, and if 
allowed to remain on the skin, or, if napkins are merely dried and 
reapplied, the intertrigo will be aggravated. 

After washing off the parts they should be dried carefully, and boric- 
acid powder, talc, or zinc stearate should be dusted on. If there is a 
tendency to chafing of opposing skin surfaces, they may be kept apart 
by wads of absorbent cotton. The digestive system should be investi- 
gated with a view of correcting any acidity in the discharges, and the 
urine should be tested for hyperacidity. In the early stages intertrigo 
usually yields readily to the application of the powder which follows: 

1$ — Zinci oxidi pulv 5ss 

Camphorae pulv 3iss 

Amyli pulv §j — M. 

Sig. — Dusting powder. 



IMPETIGO CONTAGIOSA. 

Impetigo contagiosa is a highly contagious and auto-inoculable skin 
disease, occurring most frequently among the children of the poor. 
Epidemics are often observed in institutions. The disease is caused 
by infection of the skin with the staphylococcus. An attack lasts 
from ten to fourteen days, but the child may suffer with impetigo for 
weeks, kept up by auto-inoculation. 

These lesions are most commonly seen on the face, about the nostrils 
and corners of the mouth, also on the hands, and may extend to any 
part of the body. They first appear as vesicles, which vary in size 
from that of a pin head to the diameter of a five cent piece, and are 
flattened on top. The vesicles soon become pustules, which coalesce 
and rupture, and result in the formation of grayish-yellow crusts. 
The crusts appear as though they were merely stuck on the skin, but 
are usually attached to the hairs and, if removed, leave a raw, bleeding 
surface. There is no itching, and the lesions leave no scar. 

The characteristic features of impetigo contagiosa are quite distinct, 
and the diagnosis is made on the superficial appearance of the lesions, 
their distribution, the absence of itching, with evidence of auto- 
inoculation or a history of contagion. By these definite features it 
can readily be distinguished from pustular eczema, varicella, and 
scabies. 

Treatment. — It it were not for the danger of auto-inoculation in 
children, the lesions could safely be allowed to heal spontaneously. 
They should be kept clean and healed as rapidly as possible, however, 



592 DISEASES OF THE SKIN 

to prevent their spreading. The crusts may first be softened by a 
bland oil, and then washed off with green soap and warm water. 
After the crusts are removed an ointment containing 15 grains of 
sulphur to one ounce of Lassar's paste should be applied. The gen- 
eral health of these children is usually poor, and should be improved 
by regulation of the diet, good hygiene, and the administration of 
tonics, such as cod-liver oil or iron. The preparation appended below 
has been found invaluable in the treatment of impetigo. 

1$ — Hydrargyri ammoniata gr. xx 

Petrolati' §j— M. 

FURUNCULOSIS. 

Furunculosis, in which multiple boils appear all over the body, or 
successive crops in certain regions of the body, is quite common during 
childhood. The boils are the result of a deep-seated infection of the 
skin, most frequently by the Staphylococcus pyogenes aureus, which 
attacks children whose vitality is low from malnutrition or debilitating 
disease. It rarely occurs in the very young, but may follow prickly 
heat in infancy. It is quite common to see a child's scalp, as well 
as the rest of the body, covered with boils. 

These boils vary in size, burrow deeply, are acutely inflamed, and 
very tender and painful. They terminate in suppuration with rupture, 
and the pus which is discharged may then infect other areas of skin, 
if there be any abrasion. Constitutional symptoms sometimes appear, 
and the child is restless, loses weight and strength, and may have 
slight fever. 

Treatment. — The local treatment of the individual boil depends upon 
the stage of inflammation it has reached. Suppuration may often be 
aborted by the inunction of 10 to 20 per cent, ichthyol ointment over 
the inflamed area. If suppuration has taken place the boil should be 
lanced, and the pus gently squeezed out. The cavity may then be 
wiped out with carbolic acid on the end of an applicator. In using 
pure carbolic acid care should be taken not to injure the surrounding 
skin, and, unless perfect control of the patient is assured, it is wiser 
to use hydrogen peroxide. 

Vaccine therapy is very effective both in curing and preventing 
attacks. Both autogenous and stock vaccines are used with equal 
success. In addition to these measures the child's general health 
should be built up by change of environment, with country or seashore 
life, which will do much to prevent future attacks. The diet frequently 
needs regulation, and tonics are also indicated. 

One or two applications of the following preparation will hasten 
the cure of a furuncle by rapidly bringing the pus to a focus. 

fy — Acidi salicyli 5ij 

Emp. saponis , 5ij 

Emp. diachyli 5J — M. 

Sig.— Spread on cotton cloth and apply over the boil. 



SEBORRHEA 593 



MILIARIA. 



Miliaria is a disease of infancy and childhood, which results from 
the clogging of the sweat ducts, and is most common during hot 
weather. It may, or may not, be inflammatory. The non-inflam- 
matory form is called sudamina. The lesions consist of papules of 
pin-head size, surmounted by vesicles which contain pure sweat. 
They are most abundant on the neck, chest, abdomen, and back. 

There may be a slight erythema between the papules, and there is 
usually itching, also a burning sensation. An attack subsides in the 
course of a w T eek; but, unless precautions are taken, there may be 
several outbreaks during the summer. Very slight desquamation 
follows the rupture of the vesicles. 

Treatment. — Frequent bathing, the wearing of light outer garments, 
and of silk and linen-mesh underwear are important prophylactic 
measures. Locally, boric acid solution, bran baths, or alkaline lotions 
are soothing. Dusting powders of boric acid, zinc stearate, or starch 
will dry up the vesicles. A sojourn at the seashore with sea-bathing 
will hasten the cure. 

ERYTHEMA MULTIFORME. 

Erythema multiforme is characterized by the appearance of lesions of 
many types, from simple erythema to papules, or even tubercles. 
The papular form of eruption is, perhaps, the most common in children. 
The process is acutely inflammatory, but, as a rule, there are no sub- 
jective symptoms. The eruption may be ushered in by a feeling of 
malaise or vague rheumatic pains. It disappears as suddenly as it 
comes, lasting usually a week or ten days. 

The eruption may appear on any part of the body, but is seen most 
frequently on the hands, arms, feet, and legs. There is usually some 
intestinal derangement, auto-intoxication, or ptomain poisoning, to 
which it may be attributed. 

Treatment. — The child should receive at the onset of the attack 
a course of calomel, folloAved by castor oil. Quinine and the salicylates 
should be given in small doses. A lotion containing 1 per cent, of 
phenol, or a dusting powder, should be used locally. The diet should 
be investigated in every case and carefully regulated. 

SEBORRHEA. 

Seborrhea is marked by the appearance of crusts composed of the 
secretions from overactive sweat glands, and is commonly known as 
the "milk crust. 1 ' It appears most frequently on the scalp, but may 
also occur on the forehead in infants. The crust is grayish yellow in 
color, shows a tendency to scaling, and is firmly adherent to the skin 
which, however, is not inflamed. Seborrhea is a skin disease which 
attacks poorly nourished children, and is most common in infancy and 
at puberty. 
38 



594 DISEASES OF THE SKIN 

Treatment.— The crusts should be softened by applications of warm 
olive oil or an ointment of petrolatum containing salicylic acid, 15 
grains to 1 ounce. They may then be washed off with warm, water 
and Castile soap, and an ointment containing 10 to 20 per cent, of 
sulphur should be rubbed into the scalp. The health is usually 
poor, and any existing constitutional disorders should be remedied 
in order to improve the child's general condition. 

PSORIASIS. 

Psoriasis is quite a common skin disease during childhood, and 
occurs in apparently healthy children. Lesions may be found on 
any part of the body, but are roost common on the knees, elbows, 
trunk, scalp, and extensor surfaces of the extremities. The eruption 
appears in patches, which are usually symmetrical, sharply defined, and 
composed of papules with silvery scales at the summit. The disease 
is essentially dry, but if the scales be removed a few bleeding points 
may be found underneath them. 

The course of psoriasis is generally chronic, but it sometimes 
undergoes spontaneous cure during the summer only to return in the 
fall. Occasionally there is a history of constipation, autointoxica- 
tion, or of a rheumatic tendency. Psoriasis resembles seborrhea, but 
is more widely distributed in children, not being confined to the scalp. 
It is inflammatory, and the scales are pearly white, while seborrhea is 
non-inflammatory and the scales are yellow and greasy-looking. 
Squamous syphilides may look like psoriasis, but the distribution is 
altogether different. Eczema is usually moist during infancy, and is 
not sharply defined, as is psoriasis. 

Treatment. — Psoriasis may clear up under treatment, but shows a 
persistent tendency to recur. Applications of 2 per cent, chrysarobin 
ointment are very beneficial after the scales have been removed by 
washing with warm water and Castile soap. Ointments containing 
ammoniated mercury, 20 grains to the ounce, or tar, 2 drams to the 
ounce may be used. Arsenic should be given internally after the 
inflammatory symptoms have subsided. X-ray treatment gives 
splendid results in some cases. Children with psoriasis are usually 
much benefited by seashore life and salt water bathing. Regulation 
of the diet is of prime importance. The following ointment is often of 
great benefit, if applied to lesions after removal of the scales : 

1$ — Liquoris picis carbonis . . • . . . 3i.i 

Chrysarobin gr. x 

Hydrargyri ammoniata gr. xxx 

Adipis benzoate q. s. ad. gij — M. 



TINEA. 

The two most common vegetable parasites which infest children 
are tinea tonsurans, or ringworm of the scalp, and tinea circinata, or 



TINEA TONSURANS 



595 



ringworm of the body. Favus is so very rare that it barely deserves 
mention here. Infants are rarely affected by tinea, but it is eommon in 
older children. 

TINEA TONSURANS. 

Ringworm of the scalp occurs especially in children. It is highly 
contagious, and epidemics are not infrequent in schools and institu- 
tions where children are closely congregated. The spores of this 
parasite are found on the hair shafts, and are much like the roe of fish 
in appearance. They are smaller than the spores of the parasite 
which causes ringworm on the body. 




i 



Fig. 60. — Ringworm of the scalp. Tinea tonsurans. 

Symptoms. — The eruption may be preceded by itching and swelling 
of the scalp. The lesions are reddish, greenish, or grayish-yellow 
elevated patches, which appear on the scalp and cause the hair on 
the head to fall out. The underlying scalp may become inflamed, 
and exude a yellowish gelatinous material. The hair follicles become 
erect, and give the scalp a goose-flesh appearance. A few stumps of 
broken hairs are to be found on the bald areas, and the long hairs 
are loosened. 

Diagnosis. — The diagnosis of tinea tonsurans is made by micro- 
scopic examination of the hair stumps to which a drop of liquor 
potassae has been applied. The presence of the spores is pathogno- 
monic (Fig. 60). 

Treatment. — The hair of the scalp should be cut as short as possible, 
and the scalp then well scrubbed with tincture of green soap. After 
thorough cleansing, a 1 per cent, solution of bichloride of mercury, or 



596 DISEASES OF THE SKIN 

a 5 per cent, carbolic acid solution should be applied to the scalp 
for several successive nights. Tincture of iodine, painted on the 
scalp, is also an excellent remedy. 

If there are only a few patches, these may be blistered with glacial 
acetic acid, after which a parasiticide should be used, and, in my experi- 
ence, an ointment containing nitrate of mercury, sulphur, and phenol 
is most useful. Chronic cases must be treated patiently and vigor- 
ously, since they are very stubborn and resist treatment for months 
before they are overcome. Acute or recent cases usually respond well 
to treatment. 

The following has been found to be a most effective ointment: 

3 — B. naphthol 3j 

01. cadini ' 3ij 

Ung. sulphur . . . q. s. ad. 3ij — M. 

TINEA CIRCINATA. 

Tinea circinata, or ringworm of the body, is a much milder disease 
of the skin than tinea tonsurans. It may occur on any part of the 
body, but is most common on the face, hands, and arms. It appears 
in the form of small circular spots, which spread rapidly, and several 
rings may coalesce. The spores in tinea circinata are larger than those 
found in ringworm of the scalp. There is usually an itching sensation 
around the site of the lesion. Successive applications of tincture of 
iodine or glacial acetic acid bring about rapid recovery in a few days. 
The preparations given below may be also used with equally good 
results : 

1$ — Hydrarg. ammoniata gr. v 

Adipis 5j — M. 

Sig. — For very young children. 

Or 

1$ — Resorcini gr. xx 

Sulphur prsecip., 

Zinci oxide aa 5J 

Petrolati q. s. ad. 5ij — M. 

Sig. — For ringworm of the body in older children. 

HERPES. 

Herpes, or fever blisters, are frequently seen during childhood, 
usually on the face. The eruption consists of vesicles upon a reddened 
base and containing a clear fluid. There are four varieties of herpes: 
that on the face, herpes facialis; on the lips, herpes lingualis; about 
the genitals, herpes genitalis; and on the body, herpes zoster. 

Etiology. — Quite frequently, herpes breaks out spontaneously, and 
some children seem predisposed to it. In the course of fevers, espe- 
cially cerebrospinal meningitis, malaria, influenza, pneumonia, and 
tonsillitis, herpetic eruptions are quite common. 

Symptoms. — Before the appearance of the vesicles there is usually 
a sense of itching and burning, followed by a reddened area which is 



WARTS - 597 

later the site of the eruption. A crop of tiny vesicles soon appears, 
which may later coalesce and form one large crust. The clear fluid 
contained in the "blister" never becomes purulent unless infected by 
scratching, and, if let alone, soon dries up. The attack usually lasts 
a week or ten days, but may be prolonged by the appearance of 
successive crops of vesicles. 

Diagnosis. — The diagnosis of herpes is easy, but some cases may 
suggest eczema or impetigo. Eczema itches, while herpes burns. 
The formation of pus and crusts is more common in eczema than in 
herpes. Impetigo is essentially pustular, does not occur in single 
patches, as a rule, and is characterized by its contagiousness and 
auto-inoculability. 

Treatment. — The treatment of herpes should begin with an initial 
purge and correction of the diet. Locally, applications of camphor, 
alum, stearate of zinc, or calomel are beneficial. Fowler's solution, 
gtt. i-ij, three times a day, is administered to children who show a 
disposition to recurrent outbreaks of the disease. 

HERPES ZOSTER (SHINGLES). 

Herpes zoster is quite different from other forms of herpes, and 
must be discussed separately. The eruption is on the trunk, usually the 
upper half, and follows the course of a nerve. As a rule, it is unilateral. 

Etiology. — Exposure to cold, inflammation of the nerve trunks and 
ganglia, trauma, and the season of the year, particularly winter and 
spring, are all predisposing factors. 

Symptoms. — Herpes zoster is preceded and accompanied by neuralgic 
pain, which may or may not be so severe as to require morphine for 
relief. The vesicles vary in size from that of a pin-head to a split 
pea, and, as a rule, do not coalesce, but dry up in a few days. Succes- 
sive crops appear during the attack, which usually lasts from ten to 
twenty days. 

Diagnosis. — Before the eruption is visible the neuralgic pains of 
herpes zoster may suggest pleurodynia, or pleurisy. With the appear- 
ance of a well-defined unilateral eruption, following the course of a 
nerve trunk, the diagnosis is easy. 

Treatment. — The treatment of herpes zoster should be directed 
first to the eruption, which must be protected from injury by a dress- 
ing of absorbent cotton, after the application of tincture of benzoin, 
2 per cent, powdered camphor, or a 10 per cent, ichthyol and collodion 
dressing. Pain is occasionally so severe as to call for the administra- 
tion of phenacetin, heroin, or codeine. Following the attacks there 
may be a troublesome neuritis, which will improve with the use of 
the galvanic current locally, and salicylates internally. 

WARTS (VERRUCA). 

Most warts are congenital or develop soon after birth. They are 
composed of epithelium with a central axis of bloodvessels and 



598 DISEASES OF THE SKIN 

connective tissue, and vary in size- from that of a split pea to the 
dimensions of a small tumor. Warts usually appear on the hands and 
faces of children at the age when they begin to crawl around and 
handle everything within reach. For this reason they are believed 
to be contagious, as well as auto-inoculable. 

The two varieties most commonly met with during childhood are 
the ordinary wart, verruca vulgaris, and the plane wart, or verruca 
planus juvenilis. The common wart needs no description; it is painless, 
and, except for a disfigurement, causes no trouble except that it may 
be torn and become infected. 

Plane warts are usually very numerous; they consist of soft, elevated, 
disk-like planes, varying in size from a pin-head to a split pea. They 
may be pale brown in color, or the same tint as the skin. The dura- 
tion of a wart on the skin cannot be estimated; they may come and 
go suddenly or gradually, and may last for weeks or months. 

Treatment. — A favorite method for the removal of warts is to paint 
them on several successive nights with salicylic collodion, 10 per cent, 
strength. Glacial acetic acid, containing 1 per cent, perchloride of 
mercury, applied repeatedly on the end of a match-stick, will eradicate 
a wart. If the wart has a pedicle, or stem, it may be snipped off 
with the scissors and cauterized, silver nitrate or tincture of iodine 
being then applied to the base. Plane warts may be treated with 
unguentum acidi salicylici, grains xv to the ounce. Good results may 
follow the use of small doses of magnesium sulphate three times a day. 
The children affected are usually undernourished, and will be benefited 
by a well-regulated diet and improvement in their personal hygiene. 

ALOPECIA. 

Congenital alopecia, or absence of hair, is very rare. Diffuse 
alopecia follows febrile or debilitating diseases, and a patchy alopecia 
may result from inflammation or disease of the scalp. These forms 
of alopecia are all rather uncommon, but alopecia areata is seen more 
frequently in childhood than in adult life. 

Alopecia Areata. — In alopecia areata an irregular surface of the scalp 
is entirely free from hair, up to the clean-cut margins where the long 
hairs are found. The appearance of the skin over this spot is quite 
normal. 

Etiology. — The exact cause of alopecia areata is unknown. It 
occurs with greatest frequency in dark-haired children, both sexes 
being affected equally. In some cases there is an element of heredity. 
In others there is evidently a neuropathic taint shown by a history of 
shock, grief, anxiety, or fright, as, for instance, from a lightning 
stroke. 

Reflex irritability from injury to other parts of the body, defective 
teeth, and errors in refraction followed by severe headache, may also 
be responsible for this condition. Syphilis is regarded by some 
authorities as the most important etiological factor. Epidemics of 



ALOPECIA 



599 



alopecia areata have suggested a parasitic element, but this has not 
been supported, by the isolation of any particular organism. 

Symptoms. — There are usually no symptoms preceding the appear- 
ance of an area of alopecia on the scalp. The spot appears suddenly, 
and the loss of hair is complete. The long hairs at the margin of the 
bald spot become loose, and the spot tends to grow larger, while other 
spots appear. The whole scalp may become involved and complete 
baldness result (Fig. 01). 




Fig. 61. — Alopecia areata. 



Diagnosis. — Alopecia areata must be differentiated from ringworm; 
but ringworm of the scalp rarely presents the perfectly bald patches 
of areata, for fungi are present, and broken hairs are found over the 
affected areas. 

Treatment. — Alopecia areata is very difficult to cure, and responds 
but slowly to external and internal medication. The general health 
of the child should be built up, the nervous system quieted, and any 
associated disease treated. Tonics containing cod-liver oil, strychnin, 
and iron should be administered. Salt-water bathing is very beneficial. 

Stimulating antiparasitic remedies should be applied locally, and 
of these alcohol, resorcin, turpentine, cantharides, and sulphur or 
the mercurials are, perhaps, the best. Hot compresses, used on the 
affected areas daily, promote the circulation and favor the growth 
of new hair. No hope should be held out of cure in less than a year; 
but, unless the condition becomes general, recovery is to be expected. 

A very serviceable prescription for alopecia areata is made up as 
follows: 

I$— Ammonii carbonatis gr. xx 

Tinct. cantharides 5vj 

Aquae q. s. ad. giij — M. 



600 



DISEASES OF THE SKIN 



Nsevi are congenital localized overgrowths of any element of the 
skin, and are usually associated with other developmental defects. 
Two forms of nsevi occur in children, the pigmented nsevus, or mole, 




Fig. G2. — Hairy mole. 




Fig. 63. — Hairy mole under treatment with CO2 snow. 



and the vascular nsevus, or angioma. Nsevi are found in all parts of 
the body, but occur most frequently on the face, neck, and back. 
Their etiology is obscure. Aside from disfigurement they are of little 
importance except that vascular nsevi may be injured and bleed pro- 



PEMPHIGUS NEONATORUM 601 

fusely, and moles sometimes begin to grow quickly, and become 
malignant. 

Treatment. — Small cutaneous and subcutaneous angiomata may 
disappear spontaneously. Larger ones are most successfully treated 
with radium, or may be removed by applications of CO2 snow, but the 
port-wine colored variety is very hard to efface. Electricity is some- 
times employed with great success in the removal of angiomata. 

Moles require no treatment unless they begin to grow rapidly, when 
they should be excised at once. Hairy moles are best treated with 
C0 2 snow (Figs. 02 and 03). 

GANGRENOUS DERMATITIS. 

This disease is a multiple gangrene of the skin seen during infancy, 
usually before the third year. It follows variola, varicella, vaccinia, 
and rubeola. In some cases a co-existing tuberculosis, syphilis, or 
rickets has been observed. 

Symptoms. — After one of the exanthemata, an ulcer follows the 
eruption, and a slough is thrown off. If several ulcers have coalesced 
the tissue loss may be great. Occasionally the gangrenous points 
appear on normal areas of skin. The head, shoulder, and trunk are 
the most common sites. If the ulcers are numerous, they may cause 
marked constitutional symptoms. After sloughing a process of repair 
sets in, and a vaceiniform scar is left at the site of each ulcer. 

Treatment. — The general condition of the child should be supported. 
Local treatment consists in dressing the ulcers antiseptically, and 
applying deodorants to the sloughing tissue. The outlook in the 
majority of cases is very grave, in spite of most careful treatment. 

PEMPHIGUS NEONATORUM. 

Pemphigus neonatorum is the title given to impetigo contagiosa 
bullosa occurring in the newborn. It appears in infants both sporadic- 
ally and epidemically, epidemics being more commonly seen in the 
obstetric wards of large hospitals. The disease is of infectious origin, 
and probably due to the staphylococcus aureus. 

Symptoms. — The eruption commonly appears between the fifth and 
twentieth days of a child's life, and shows a predilection for the abdo- 
men, inguinal region, face, and hands, but the lesions may appear on 
any part of the body. The eruption consists of vesicles and bullae 
situated on an erythematous base. They vary in size, and contain 
either serous or purulent fluid which spreads the infection when the 
lesions burst. In mild cases there are few constitutional symptoms; 
when severe, the lesions are very numerous and are accompanied by 
diarrhea, anorexia, fever, and exhaustion. 

Diagnosis. — If there are no other signs of syphilis present, the absence 
of lesions on the soles and palms will differentiate pemphigus neona- 
torum from syphilitic pemphigus. 



602 DISEASES OF THE SKIN 

Treatment. — Absolute cleanliness is essential, and when the involved 
area is large, warm baths should be given twice daily. Dusting 
powders of starch, boric acid, bismuth subnitrate, or zinc stearate may 
be used. The vesicles may be opened, and an ointment of 2 per 
cent, ammoniated mercury applied. Supportive treatment is indi- 
cated in severe cases, as it is the bottle-fed, cachetic baby that usually 
succumbs to this disease. Healthy babies generally recover in from 
two to three weeks, and in these infants the disease never approaches a 
severe degree. 

DERMATITIS EXFOLIATIVA NEONATORUM. 

This is also known as Ritter's disease. It is very rare, and is believed 
to be closely related to pemphigus. It occurs in infants between the 
first and fifth weeks, most commonly in foundling asylums. The 
cause of Ritter's disease is unknown. Its relation to pemphigus is 
upheld by some authorities, while others consider it to be merely an 
exaggeration of the normal exfoliation of the newborn. The majority 
of cases have been observed in boys. 

Symptoms. — In some cases the disease begins with a dryness of the 
skin, while in others there is inflammation of the oral mucous mem- 
brane. This is followed by a diffuse redness all over the body. As the 
hyperemia spreads, the area which first became reddened begins to 
desquamate. The desquamation may be perfectly dry, or accompanied 
by the formation of bullae filled with fluid. After desquamation, the 
skin is irritable for a few days, and then returns to normal. There is 
usually no fever, and uncomplicated cases show no systemic 
disturbances. 

Delicate children who have Ritter's disease are apt to develop com- 
plications, such as furunculosis, gangrene, gastro-intestinal disturbance, 
or pneumonia, which usually brings about a fatal termination, but 
healthy children quite frequently recover. The disease shows a 
mortality-rate of about 50 per cent. 

Diagnosis. — The differentiation between Ritter's disease and pem- 
phigus is very difficult, since the two diseases are related. Ritter's 
disease is differentiated from the general exfoliation of the skin caused 
by syphilis by the absence of other evidences of lues. 

Treatment. — Prophylaxis consists in cleanliness, and the avoidance 
of all local irritation. The child's state of nutrition usually needs 
improvement, and the warmth of the body should be maintained. 
Locally, an ointment containing 1 per cent, salicylic acid or phenol 
should be employed, or the following: 

1$ — Hydrarg. ammoniata 3ij 

Petrolati S i J — M. 

MOLLUSCUM CONTAGIOSUM. 

Molluscum contagiosum is a form of contagious wart within which 
there occurs a peculiar degeneration. The affection is much more 



PARASITIC SKIN DISEASES 003 

common in children than in adults, and epidemics are not uncommonly 
seen in institutions. The etiology of molluscum contagiosum is still 
obscure, but the theory of the parasitic nature of the disease has been 
universally accepted, although no definite organism has been isolated. 

Symptoms. — The eruption appears as small, firm nodules, which are 
tense and shiny, of whitish color, and waxy appearance. There is a 
central umbilication from which sebaceous material may be expressed. 
The eruption occurs principally upon the face, neck, and arms. 

Diagnosis. — Molluscum contagiosum docs not resemble any other 
skin disease. Warts of the ordinary type may possibly be mistaken 
for it, but they do not commonly appear on the face, and have no 
central umbilication. 

Treatment. — Multiple punctures of the nodules will usually cause 
their disappearance in a few days. If there be but few lesions, the 
sebaceous material may be squeezed out of each individual nodule, 
and a cure thus effected. If the disease is widespread over the body, 
applications of tincture of green soap or 5 per cent, sulphur ointment 
are advisable. 

PARASITIC SKIN DISEASES. 

Parasitic skin diseases are more common among the children of the 
poor, but may be seen in all classes, on account of the close contact of 
children at school and at play. Both animal and vegetable parasites 
infest the skin. Of the animal parasites, pediculi and the itch mite 
are most frequently encountered, while fungi which produce ringworm 
of the scalp and favus are the most common vegetable parasites. 

Pediculosis. — Pediculosis is that condition in which the child is the 
host of pediculi or lice. In young children the pediculosis capitis, 
or head louse, is most frequently found; occasionally the crab louse, or 
pediculosis pubis, will be observed on the eyelids of young children. 
Later in childhood one finds the pediculosis corporis, or body louse, and 
the pediculosis pubis. 

The pediculi found in the scalp, pubic hair, and body hair form 
respectively three distinct varieties of lice. They are very prolific, 
each female when three weeks old laying about fifty eggs. The eggs 
of the body louse are deposited in the underclothing, but the eggs 
of the other types are found attached to the hairs, and are knoAvn as 
nits. 

Symptoms. — After attaching itself to the skin the parasite sucks the 
blood, and causes intense irritation and itching, which result in vigor- 
ous scratching on the part of the child. Many cases of eczema, especi- 
ally of the scalp, have their beginning as pediculosis. In every case 
there is severe inflammation of the skin from the irritation and scratch- 
ing, and the lymphatic glands draining the affected area may become 
enlarged, as is often the case with the enlargement of the postcervical 
glands seen in pediculosis capitis. 

Diagnosis. — The diagnosis is made by identifying the pediculi, 
which may readily be seen under a low power glass. The nits are 



604 DISEASES OF THE SKIN 

visible to the naked eye. Pediculosis corporis is sometimes confused 
with scabies; but the distribution of the lesions differs, and no burrows 
are to be found in pediculosis corporis. 

Treatment. — Removal of the hair from the affected regions is a great 
help in every case. If this be objected to, the hair must be gone over 
carefully with a fine-tooth comb. Kerosene is a good application, but 
is disagreeable, and a solution of bichloride of mercury, 1 grain to the 
ounce of water, is just as effective. To this may be added dilute 
acetic acid, which will loosen the nits, and facilitate their removal from 
the hairs. 

If the irritation is severe, a 5 per cent, phenol solution may be 
applied to the scalp, or a 10 per cent, boric acid ointment rubbed in. 
The head should be thoroughly washed each morning, and the para- 
siticide reapplied until all pediculi and nits have been removed. 

Pediculosis corporis may be eradicated by daily bathing, and a 
change of underclothing after each bath. The discarded under- 
garments should be soaked in a 5 per cent, carbolic solution before 
they are used again. An* ointment containing 5 per cent, phenol or 
the following prescription is often beneficial: 

3— Olei olivse fgiij 

Olei petrolei f §vj 

Balsam Peruv f §j — M. 

Sig. — Apply to scalp on retiring. 

SCABIES. 

Scabies is a contagious skin disease due to the presence of the itch 
mite, or acarus scabiei, in the skin. The female buries herself in the 
skin, making a burrow in which she deposits eggs and feces. This 
produces on the skin an eruption of vesicles, pustules, and nodules. 
The itching is severe, and is worse at night, so that scratch marks are 
added to the eruption. The burrows are elevated, and grayish in 
color; with the aid of a magnifying glass the parasite may be seen at 
one end. 

The distribution of the eruption is characteristic, for the mites seek 
moist, warm places for burrowing, therefore the lesions of scabies are 
most abundant in the interdigital spaces, the wrists, the flexor sur- 
faces of the forearms, between the toes, in the under surfaces of the 
thighs, and on the scrotum and penis. 

Diagnosis. — The diagnosis of scabies is certain when the burrows 
have once been demonstrated in the skin of the child. The distribution 
of the eruption, the history of contagion, and the itching, worse at 
night, are points which differentiate scabies from pediculosis or eczema. 
An eczema frequently appears as a result of scabies, and may tend to 
mask the original condition. 

Treatment. — The treatment of scabies consists, for the main part, 
in the destruction of the itch mite, but this is difficult to accomplish 
without causing a dermatitis or eczema by the parasiticide used. The 



DERMATITIS MEDICAMENTOSA 



605 



first step should be to remove the clothing and bedclothes, and to 
sterilize them. The child should be given a warm bath, using plenty 
of soap, followed by a vigorous rubbing with a rough towel. The skin 
should then be anointed with an ointment containing balsam of Peru 
and sulphur, 1 dram each to the ounce of petrolatum. This ointment 
should be reapplied for three successive evenings following the first 
application, but no baths should be given during this time, and the 
same underclothing should be worn. After the fourth application of 
the parasiticide, another warm bath is given, and fresh underclothing 
put on. 

If dermatitis or eczema results from the treatment, this should now 
receive attention. If not completely eradicated, a second course of 
treatment similar to the first will usually result in the disappearance 
of all evidences of scabies. 

When treating scabies in very young infants, a solution of styrax, 
one-half ounce to the ounce of lanolin, is just as effective as the 
sulphur preparation, and is less liable to cause dermatitis. 

B — Sulphuris 3ij 

Hydrarg. amnioniata . . . gr. xx 

Creosote gtt. xx 

Lard q. s. ad. Six — M. 

Sig. — Apply locally. 




Bromide rash. 



DERMATITIS MEDICAMENTOSA. 

This includes all eruptions caused by the administration of drugs. 
As a rule, the skin lesions appear after some days or weeks of con- 
tinuous dosage; occasionally, however, they may develop after a very 
small amount of the medicine has been taken. 

Certain drugs, especially the bromides, belladonna, the iodides, 
quinin, salicylic acid, mercury, arsenic, and many coal-tar derivatives, 
are apt to produce cutaneous eruptions. Some of these, as the bro- 



606 



DISEASES OF THE SKIN 



mides, iodides, and belladonna, usually produce a rash, others less 
regularly do so. Some children, too, are very susceptible. 

The rashes caused by the administration of bromides are commonly 
pustular, less often furuncular and carbuncular. There may occasion- 
ally be some superficial ulceration; very rarely papillomatous or 
vegetative lesions occur. Bromide lesions do not leave any permanent 
disfigurement, although the rash may persist for four or five weeks 
after the bromides have been discontinued (Fig. 64). 




Fig. 65. — Tuberculosis cutis. 



TUBERCULOSIS CUTIS. 

The tubercle bacillus may also produce lesions of the skin, usually 
suppurative or ulcerative in character. These lesions are generally 
due to the extension to the skin of some underlying tuberculous process. 
The superficial skin is more or less destroyed, the edges are red and 
undermined, and the granulations thinly covered with pus. The 
lesions spread slowly and cause very little pain. Occasionally the 
disease assumes a papulopustular form, which is most commonly seen 
on the face and upper extremities. An ulcerative papillomatous 
tuberculosis occasionally occurs, and is, as a rule, found on the lower 
leg or hand (Fig. 65). 



CHAPTER XXI. 

DISEASES OF THE EAR. 

Diseases of the ear are quite common in children at all ages. 
During infancy, otitis is usually primary, but in later child life it 
is commonly secondary to one of the exanthemata. 

FOREIGN BODIES IN THE EAR. 

The presence of foreign bodies in the ear is not usually attended 
with severe symptoms or grave consequences, hut efforts at removal, 
if not skilfully directed, may do much harm. Children are in the 
habit of putting things in the ear, and for this reason the variety of 
articles which has been removed from the ears of children is large. 
They are divided into three groups: animate objects, such as bugs 
and insects — inanimate objects influenced by moisture, such as beans, 
onions, tea and wheat — and inanimate objects uninfluenced by mois- 
ture, such as beads, pebbles, and buttons. Insects should be killed 
by filling the auditory canal with warm water or whisky before an 
attempt is made to syringe them out. 

Objects in the ear influenced by moisture may be reduced in size 
by instilling pure alcohol before attempting extraction. Even if the 
object be uninfluenced by moisture, instillation of alcohol will tend 
to reduce any swelling of the auditory canal and facilitate its removal. 
Syringing an object out of the ear is preferable to using instruments, 
and should be successful if the stream can be directed back of the 
foreign body. In some cases turning the head sidewise with the ear 
lowermost, and striking the head from below, may dislodge the 
object. 

ACUTE OTITIS MEDIA. 

Acute otitis media is an inflammation of the middle ear, and may 
be catarrhal or suppurative. 

Etiology. — In severe cases of scarlet fever, diphtheria, and to a less 
degree in measles, especially when the throat symptoms are severe, 
there is a distinct tendency to inflammation of the middle ear, and 
there is certainly a probability of more or less inflammation of the 
ear in all infectious diseases of childhood. In bathing infants, water 
may gain entrance to the tympanic cavity through the upper segment 
of the drumhead, which is not always closed at birth, and this gives 
rise to otitis media. 

The mucous membrane lining the tympanic cavity is embryonic 
in type during infancy, and this also predisposes to inflammation. 



608 DISEASES OF THE EAR 

Cachexia and bronchitis are two important factors in the etiology of 
otitis media in infancy. Coughing, vomiting and sneezing may force 
matter through the Eustachian tubes into the middle ear and thus 
give rise to suppuration. Adenoids and diseased tonsils, syphilis and 
tuberculosis, all predispose to middle-ear disease during childhood. 

It has been stated that pathogenic bacteria may be found normally 
in the tympanic cavity, and, therefore, any local change in the con- 
dition of the mucous membrane, such as congestion from any cause, 
may result in an otitis media. 

Otitis media is sometimes present in the newborn, and is supposed 
to be caused by the forcible entrance of amniotic fluid into the middle 
ear during delivery. 

Pathology.— The pathological changes vary from the simple catarrhal 
inflammation which usually accompanies catarrh of the rhinopharynx 
or measles to the phlegmonous form with infiltration and purulent 
secretion seen after scarlet fever, influenza or diphtheria. The simple 
catarrhal form of otitis media is characterized by swelling and cloud- 
ing of the mucosa, and the production of a slight quantity of sero-pus. 
There is usually very slight pain and the inflammation subsides in the 
course of a few days with no serious results following. This form is 
seen most frequently during infancy. 

In older children the suppurative form is most common. It is caused 
by the action of a great number of virulent bacteria on a devitalized 
mucous membrane in the tympanic cavity. The membrane is first 
hyperemic, then it becomes infiltrated, and there is a purulent exudate. 
This inflammatory process may extend to the cellular tissues above 
the tympanum. The Eustachian tube becomes blocked up and the 
tympanic membrane is finally ruptured by the force of the pent-up 
secretion in the tympanic cavity. Necrosis of the ossicles may result, 
and, by extension, the inflammation may give rise to periostitis, 
pachymeningitis, thrombosis of the lateral sinus, and cerebral abscess. 

Bacteriology. — The organisms found most frequently in otitis media 
are the streptococcus, staphylococcus, and pneumococcus. The tuber- 
cle bacillus may be present in chronic cases, and the Klebs-Loeffler 
bacillus has been isolated in cases of otitis secondary to diphtheria. 

Symptoms. — The symptoms of acute otitis media are very often 
variable and obscure. In infants with cachexia as an underlying 
cause, there may be no subjective symptoms. On inspection, the 
drumhead is slightly reddened and a small amount of slimy secretion 
may be found in the auditory canal. The nutrition is often dis- 
turbed in otitis of infancy, and the child nurses poorly. It may refuse 
to nurse except on the side which allows it to place the affected ear 
to the mother's breast. It is peevish, twists its head or drops it to 
one side, and cries out continually. The pain is worse at night and the 
fever is higher than during the day, so that the child is restless and 
may make sudden outcries in its sleep. 

Pain and temperature are the two constant features of otitis in 
children. The temperature range in these cases is from 100° F. to 



ACUTE OTITIS MEDIA 609 

104° F. In some cases there is anorexia, nausea, vomiting, and marked 
apathy. These symptoms usually persist for a week or ten days when 
a purulent secretion is found in the canal. Examination of the ear 
drum will usually reveal the site of rupture of the tympanic membrane. 
The discharge of pus is followed by a drop in temperature and rapid 
subsidence of all symptoms. As a rule there are no complications in 
this form of otitis during infancy. 

In older children the symptoms are more severe. The pain is 
intense and becomes excruciating just before rupture of the drum- 
head. Evidences of meningeal and labyrinthine irritation are present 
and include nystagmus, vomiting, convulsions, and unconsciousness. 
Headache and delirium are also not uncommon. A child with otitis 
will often complain of noises heard in the ear. It is very restless, cries 
incessantly and rubs or strikes the ear with its hand. 

Otoscopic examination reveals the ear drum markedly congested 
and irregular in contour. The upper and posterior walls of the meatus 
are swollen. The mastoid is very tender and there is a swelling of the 
tissues covering the bone and extending downward along the whole 
side of the neck and forward to the retromaxillary fossa. The inflam- 
mation may not go on to suppuration if the symptoms are mild, but 
as a rule there is pus formation which causes first a bulging of the 
tympanic membrane, and then, as the tympanic cavity fills up with 
pus, the ear drum is ruptured. 

The temperature in otitis media purulenta is the most constant 
sign and may be the only indication of a complication in one of the 
exanthemata. It usually reaches 102° F., but the course is irregular 
and many cases range from 103° F. to 105° F. until rupture of the 
membrane, when the temperature falls and other symptoms subside. 
If the drumhead be resistant so that rupture is delayed, the suppura- 
tive process may extend down the neck into the throat and cause a 
retropharyngeal abscess, or into the middle fossa of the skull, or to 
the lateral sinus. 

During the course of diphtheria, measles, scarlet fever or typhoid 
fever, many of the symptoms of an otitis media may be easily over- 
looked or attributed to the primary disease, so that a routine examina- 
tion of the ears should be made during the course of all exanthemata. 

Diagnosis. — An early diagnosis of acute purulent otitis media, while 
it is apt to be very difficult if the otitis is secondary, is important, as 
the child's future hearing may depend upon the time that it is made. 
A diagnosis after rupture of the drumhead and perhaps threatened 
mastoiditis or necrosis of the ossicles, is, of course, a simple procedure. 
An otoscopic examination is always necessary, since many of the 
symptoms of a secondary otitis may be attributed to meningeal irri- 
tation from the primary disease. 

Some cases of otitis media in infants, when the symptoms are mild, 
may even fail to show any positive signs of otitis on otoscopic examina- 
tion. Fever may be the only manifestation, and in the absence of any 
signs in the ear, the diagnosis must be made by exclusion of any 
39 



610 DISEASES OF THE EAR 

cause for fever in the throat, lungs or gastro-intestinal tract. Older 
children will complain of pain or tenderness about the ear, or of deaf- 
ness and noises heard in the ear. 

Furunculosis or foreign bodies in the auditory canal may produce 
symptoms which simulate otitis media, but their presence is quickly 
revealed by otoscopic examination. A case of primary acute suppura- 
tive otitis media presents no difficulty in diagnosis in older children, 
and, if its frequency in infants during cold weather be borne in mind, 
it should not be overlooked in infancy. 

Prognosis. — The prognosis in a catarrhal otitis media is uniformly 
good. The outlook in an acute purulent otitis media depends upon 
the early diagnosis, and presence or absence of complications. The 
most unfavorable cases are those following scarlet fever. The mortality 
rate of middle-ear disease in children is below 1 per cent. 

Complications and Sequelae. — Mastoiditis is the most frequent com- 
plication of purulent otitis media. 

Meningitis. — Meningitis is more often a complication of chronic 
otitis media but may follow an acute attack. There are two varieties : 
the serous and purulent. It results from infection through the roof 
of the tympanum in most cases, but may be secondary to thrombosis 
of the lateral sinus, or rupture of a cerebral abscess. The symptoms 
come on suddenly and there is headache, contraction of the pupil and 
nystagmus toward the affected ear. The pulse is rapid, the respirations 
increased and projectile vomiting may occur. The patient is ataxic, 
the muscles of the face and extremities are drawn or contracted, and 
the head is retracted by the contraction of the head muscles. 

As the disease progresses, delirium is followed by somnolence or 
apathy and loss of memory. The distinction between serous and puru- 
lent meningitis is made by examination of the spinal fluid, which shows 
no pus or bacteria in the former, and an abundance in the latter. The 
prognosis of the serous meningitis is good, while the purulent form is 
almost invariably fatal. 

* Brain Abscess. — Middle-ear disease is the most frequent cause of 
abscess of the brain, but it usually follows chronic otitis media. The 
infection gains access through the bone, veins or dura mater, and 
in most cases the abscess is in the temporosphenoidal lobe. The 
symptoms are pain, vomiting, subnormal temperature, slow pulse, 
constipation and retention of urine. The child is usually apathetic. 
Localizing symptoms depend upon the site of the abscess. The prog- 
nosis of brain abscess is, as a rule, bad, but early operation may often 
result in recovery. 

Septic Sinus Thrombosis. — This complication is caused by the occlu- 
sion of the lateral sinus by an infected clot, due to a loss of integrity 
of the intima of the sinus. It usually follows mastoiditis or labyrin- 
thine inflammation. The symptoms are severe. There is a widely 
fluctuating temperature with chills, violent headache and a marked 
tenderness over the posterior triangle of the neck and jugular vein. 
Vomiting is a frequent occurrence and convulsions are not unusual. 



ACUTE OTITIS MEDIA 611 

The child grows apathetic and stuporous and coma precedes death 
which usually occurs in twenty-four to forty-eight hours. 

Facial Paralysis. — Facial paralysis is more frequently a complica- 
tion of chronic otitis media, and is due to an extension of the inflam- 
matory process from the bone to the seventh nerve where it passes 
through the canal. 

Labyrinthitis. — Labyrinthitis may be cither suppurative or non- 
suppurative. Jt is rarely seen as a complication of otitis media where 
treatment has been prompt and thorough. 

Treatment of Otitis Media. — Because of the dire results which some- 
times follow an acute attack of otitis media in children, prophylaxis 
is an extremely important part of the treatment. Tonsils and adenoids, 
as common predisposing factors, should be removed. During the 
course of the exanthemata and other acute febrile diseases, the naso- 
pharynx should receive special attention and careful cleansing. Warm 
salt water or liquid albolene should be instilled into the nose twice 
daily with a dropper; the use of nasal douches or syringes should be 
avoided. The ears should be syringed daily with warm boric acid 
solution. 

A mild attack of acute catarrhal otitis media will often subside if 
the ear be carefully irrigated with saline solution at a temperature of 
110° F. The child should be put to bed, the diet restricted, and a 
thorough purge administered. Local blood-letting may abort sup- 
puration in a child, but should never be practised in an infant. The 
artificial leech is usually employed. 

Hot applications are soothing for the pain, and dry heat is prefer- 
able to wet heat. The best results are obtained from the use of rays 
of a high -candle-power electric light (200 to 300 c. p.), but a hot- 
water bag or a bag of salt heated may serve the purpose. It may be 
necessary to instil a 4 per cent, cocaine or 5 per cent, phenol solution 
into the ear for the pain, but the mother should be warned against 
dropping oil of any kind into the auditory canal. 

Frequent otoscopic examinations should be made if a child has 
acute otitis, and as soon as suppuration is indicated the drumhead 
should be incised. ^Myringotomy is such an important measure in 
treatment that it should be done if there is the slightest suspicion of 
pus, for in many cases where the drumhead is incised and no pus 
obtained there has been instant amelioration of symptoms without 
pus formation. The incision should be long and curved to allow the 
discharge to flow through it. The after-treatment may be either wet 
or dry. 

The dry method consists in wiping out the exudate from the 
external auditory canal and the use of silver nitrate, 3 to 5 grains to 
the ounce, as an application in the tympanic cavity. The ear may 
then be dusted with equal parts of boric acid and zinc oxide. The wet 
method is carried out by repeated syringing of the ear with hot salt 
solution or copper or zinc sulphate, gr. viii to the ounce of water. 

If the discharge lessens and the temperature persists, the drainage 



612 DISEASES OF THE EAR 

is imperfect and a secondary incision may be necessary. If the dis- 
charge persists, a few drops of 2 per cent, silver nitrate should be 
dropped into the tympanic cavity, or the tympanic membrane may be 
cauterized with trichloracetic acid. A fetid discharge may be alle- 
viated by the use of hydrogen peroxide or compound tincture of ben- 
zoin in a syringe. An aurist should be consulted if the discharge does 
not cease within a month. The presence of adenoids and other con- 
ditions in the nasopharynx also has a tendency to prolong an attack 
of otitis, and these conditions should be corrected as soon as possible. 

The use of vaccines has been the subject of much discussion recently, 
and my experience with them has been very satisfactory. Autogenous 
vaccines are made by suspending dead bacteria in normal salt solu- 
tion after a culture has been obtained from the pus. In this way the 
specific organism is isolated and used after subjecting it to a tem- 
perature of 60° C. for forty-five minutes. Because of the reaction 
it produces, vaccine therapy is contra-indicated in cases where there is 
a debilitated condition of the patient, or if the child be in a state of 
profound sepsis. 

Subacute and chronic cases are benefited most by the administra- 
tion of vaccines, for the child is, as a rule, in better physical condition 
than during acute attacks. Cases which respond to vaccine treatment 
undergo rapid recovery and complications of otitis are rarely seen. 
A marked improvement is often observed when vaccines are given 
following operation for any of the various complications of otitis. It 
is usually administered a week or so after operation. 

If vaccine therapy is decided upon in a case of otitis, injections 
should be given in increasing doses every three or four days, but as 
soon as reaction symptoms, such as a feeling of exhaustion, etc., are 
noticed, the injections should be discontinued for a week or so until 
the vital forces are reestablished. 

Stock vaccines, which may be had from the biological departments 
of the large drug firms, do not give as uniformly good results as the 
autogenous vaccines, because they do not contain the same strains 
of organism which the patient must react against. The antibodies 
which are formed following their injection are therefore not exactly 
suited to counteract the specific bacteria and endotoxin present. 

In many cases they have the objectionable feature of devitalizing 
the patient with no beneficial results in return. The leukocyte extract 
of Hiss may be given with safety in those cases of debility and pro- 
found sepsis where the use of vaccines is contraindicated. It contains 
the elements of the leukocyte necessary to combat the bacteria and 
endotoxin, and its administration in no way exerts any influence on 
the vital forces. 

CHRONIC SUPPURATIVE OTITIS MEDIA. 

. Inflammation of the middle ear which has become chronic is seen 
quite frequently during childhood. It is usually characterized by a 



CHRONIC SUPPURATIVE OTITIS MEDIA 613 

fetid discharge and an absence of subjective symptoms except during 
acute exacerbations, which are sometimes quite frequent. 

Etiology. — Chronic suppurative otitis media usually follows scarlet 
fever, measles or influenza, and is also frequently seen after diphtheria 
and typhoid fever. Occasionally a case will develop in certain cachec- 
tic conditions without previous acute phenomena, but, as a rule, there 
is a history of an acute purulent otitis media with spontaneous rupture 
of the drumhead. 

On otoscopic examination, there is generally found a state of imper- 
fect drainage caused by the location of the perforation of the drum- 
head or the size of the aperture. Catarrhal conditions in the naso- 
pharynx and the presence of adenoids are also predisposing factors. 
It usually develops in weakly, anemic or tubercular children, and 
tuberculous otitis is chronic from the onset. Chronic otitis involves 
the tympanic membrane, external meatus, bony walls of the middle 
ear, and sometimes the labyrinth. 

Symptoms. — Persistent discharge of pus is perhaps the most constant 
symptom. In some cases it is very slight, but can usually be found on 
otoscopic examination. In neglected cases it becomes fetid and may 
also be blood streaked due to ulceration, in other cases the discharge 
is more like mucus than pus. 

There may be headache or fulness in the head, and often the child 
may complain of noises in the ear. Pain is usually due to ulceration 
or pus retention. Acute exacerbations, in which there is pronounced 
pain, mastoid tenderness and elevation of temperature, are of frequent 
occurrence. 

Prognosis. — The future hearing of the child, with a chronic purulent 
otitis media, depends upon the site of the perforation and the extent 
of involvement. If there is a central perforation, the hearing may be 
but slightly affected, but if there is marginal perforation with bone 
necrosis, there may be serious impairment of hearing. 

Treatment. — The treatment of chronic otitis media in children should 
be conservative. If drainage is poor because of a small perforation 
in the tympanic membrane, an incision should be made and the 
opening enlarged. The ear should be syringed with bichloride solution, 
1 to 10,000, or hydrogen peroxide, saturated solution of boric acid, or 
normal salt solution, if the wet method is to be followed. 

The dry method consists in wiping out the secretion, the instillation 
of an astringent, and the application of a powder which is blown into 
the ear. Silver nitrate 3 to 10 per cent., alcohol 50 per cent., and argy- 
rol are largely used in the middle ear, and in some cases the cautery 
may be necessary for polypi and granulations. Boric acid, aristol 
and iodoform are used as dusting powders, but they must be finely 
pulverized, and care should be taken that one does not put enough 
into the canal to block drainage. 

If there is bone necrosis or a large number of granulations, operation 
is necessary to effect a cure and prevent intracranial complications or 
mastoiditis. If the child has adenoids, they should be removed and 
other nasopharyngeal defects remedied. 



614 DISEASES OF THE EAR 

Autogenous vaccines are especially to be recommended in chronic 
suppurative otitis media, as very many excellent results have followed 
their administration. In addition to these measures for treatment 
of chronic middle-ear disease, attention should always be directed to 
the general health of the child. Frequently the patient is found to 
be in poor physical condition — anemic, rheumatic or syphilitic, and 
proper treatment of these conditions will aid materially in the subsi- 
dence of the ear trouble. 

ACUTE MASTOIDITIS. 

Acute infection of the mastoid process in children is practically 
always secondary to a suppurative otitis media. The occurrence of 
primary mastoiditis as a result of cold, or trauma, or furunculosis of 
the external auditory canal posteriorly, is so rare as to be disregarded 
in the discussion of mastoiditis during childhood. 

In children, probably all suppurative middle-ear infections also 
involve the mastoid cells, and it is difficult to separate suppuration 
of the middle ear from that of the mastoid. If, however, a case of 
otitis media presents no symptoms of mastoiditis, it is regarded as a 
simple case of otitis media. 

Etiology.^-The ease with which pus may enter the mastoid antrum 
causes mastoiditis to be a frequent complication of acute purulent 
otitis media in children. The external bony wall is thinner than in 
adult life, the petrosquamous suture, which is persistent in some 
cases, passes through a foramen on the inside of the skull and appears 
externally behind the glenoid fossa and tympanic ring, and pus may 
also find its way externally more readily through the open fissura 
mastoidea squamosa. 

In addition to this, the Eustachian tube is short and has a wide 
calibre, which invites infection through this source. Involvement of 
the mastoid is much more apt to occur where there is not sufficient 
drainage or when incision of the drumhead has been too long delayed 
in an attack of purulent otitis media. As a general rule, streptococcal 
infection is most liable to give rise to mastoiditis. Mastoiditis has 
been observed as early as the second month, but most cases are seen 
after the second year. 

Symptoms. — The symptoms of mastoiditis are both local and 
general. Those referable to the mastoid are due to pressure - from 
retention of secretion within the cells. Pain is severe only when the 
cortex is thin, with more or less necrosis due to otitis and periostitis. 
Redness, tenderness on pressure and swelling over the mastoid process 
are present in almost every case. Otorrhea is usually increased and, 
in the absence of other signs of mastoiditis, a profuse discharge is 
indicative of mastoid involvement. 

Otoscopic examination reveals a bulging or drooping of the postero- 
superior wall of the osseous canal. There is usually a small central 
perforation in the drumhead and, in some cases, granulations may 



ACUTE MASTOIDITIS 615 

be observed protruding from this aperature and obstructing the 
drainage. Of the general symptoms of mastoiditis, elevation of tem- 
perature is the most constant. It ranges from 99.5° to 105° F. The 
pulse and respiratory rates are increased correspondingly with the 
elevation of temperature. The child is restless at night and may cry 
out while asleep. During the day it is cross and irritable. Occasion- 
ally there is vertigo, vomiting and a convulsion at the onset of the 
disease. 

Diagnosis. — An early diagnosis of acute mastoiditis in children not 
only prevents the occurrence of complications, but may save the life 
of a child, for delay in operation always subjects the patient to certain 
dangers. The diagnosis is made chiefly on the clinical symptoms, 
physical signs, and the findings on otoscopic examination. 

Symptoms, while important, are not alike in all cases, and for this 
reason careful examination is sometimes necessary to detect mastoid 
inflammation. A continuous discharge from the middle ear for over 
four weeks, with fever and impaired hearing, strongly suggests an 
abscess of the mastoid. One of the most important diagnostic signs 
is the drooping of the posterosuperior wall of the osseous canal. The 
ar-ray and transillumination are sometimes used as an aid to diagnosis. 

Acute mastoiditis must be differentiated from furunculosis of the 
external auditory canal and scalp, from erysipelas of the auricular 
region and from lymphangitis of the scalp. Furunculosis of the 
external auditory canal may give rise to many of the local signs of 
mastoiditis, including pain, swelling, tenderness and edema over the 
mastoid. An otoscopic examination quickly reveals the site of the 
furuncle, and shows a normal tympanic membrane and osseous canal. 
Hearing is affected in furunculosis only when there is mechanical 
obstruction by the furuncle. The temperature is rarely elevated. 

Erysipelas, involving the region of the auricle, may be accompanied 
by symptoms suggesting mastoiditis, but careful inspection will 
usually reveal the nature of this disease, and otoscopic examination 
shows a normal tympanum and osseous canal. In children with 
pediculosis capitis, a lymphangitis may occur which will involve the 
mastoid lymph glands, and in some cases simulate mastoiditis. 

The differentiation between this affection and mastoiditis is based 
upon the absence of any ear condition on otoscopic examination, and 
the finding of the pediculi and the bilateral involvement. An impor- 
tant differential feature in all of these conditions is the absence of 
any previous history of ear disease (except rarely as a coincidence). 

Complications. — The complications of acute mastoiditis are Bezold's 
mastoiditis, caries and necrosis of bone extending in any direction, 
facial paralysis and brain abscess. 

Treatment. — The most important prophylactic measure against 
mastoiditis is early incision of the drumhead in acute purulent otitis 
media. In otitis following influenza, typhoid fever or pneumonia, 
the drumhead should be incised immediately, not waiting for bulging. 
When a case of acute mastoiditis is seen before spontaneous perfora- 



616 DISEASES OF THE EAR 

tion of the tympanic membrane has taken place, the drumhead should 
be freely incised at the point of greatest bulging. This relieves press- 
ure and thus retards necrosis. 

The child with mastoiditis should be put to bed and be given a 
course of calomel and a dose of aconite. If the case is seen at the 
onset, an ice-bag may be placed over the mastoid for twelve to 
twenty-four hours, but once removed, should not be reapplied. Dry 
heat obtained by the use of the hot-water bag is often preferable for 
the relief of pain, and in some cases an opiate must be given. Leech- 
ing is of great value, but should not be used in infants and is difficult 
to perform in children. 

In every case it is most desirable to obtain a reaction to inflam- 
mation, and this may be promoted sometimes by hot irrigations, using 
a 1 to 5000 bichloride solution. Bier's hyperemia has been resorted 
to with this object in view, but authorities disagree as to its efficiency, 
and some writers claim that the disease is found more widespread 
after its use. The leukodescent light may be mentioned as another 
means of securing a reaction to inflammation, but its use is by no 
means universal. 

The treatment outlined so far should always be carried out in an 
endeavor to abort a threatened mastoiditis, but once it becomes 
apparent that the acute symptoms are not modified or the infection 
eradicated, operation should be advised without further delay. 

If performed early, a mastoid operation is not formidable and the 
results are good, but a delay of a few days or a week may make a 
radical operation necessary because of the extent of involvement. 
In advanced tuberculosis, general debility or bilateral involvement 
in bottle-fed babies, however, operation should be attempted only 
if life is endangered by the virulence of the infection. 



CHAPTER XXII. 
THE SPECIFIC INFECTIOUS DISEASES. 

TYPHOID FEVER. 

Typhoid fever is an acute general infection caused by Ebertli's 
bacillus, the bacillus typhosus. It occurs during intra-uterine life, 
may exist in the newborn, is comparatively rare in infancy, and more 
common in childhood. It is generally contracted by drinking water 
which contains typhoid bacilli, by the use of infected ice, by drinking 
milk which has been diluted with contaminated water, by using dishes, 
cans, or other utensils which have been washed with such water, and 
by eating uncooked vegetables, such as lettuce, celery, and water 
cress, also oysters. In an infected locality the only safety lies in 
boiling for five minutes all water used for drinking and other house- 
hold purposes. With infants and children, the water used in the daily 
bath may be a source of infection owing to their habit of splashing 
it about and putting their wet fingers in their mouths. 

Etiology. — Typhoid bacilli are present in the feces and urine of all 
typhoid fever patients, and the prevalence of typhoid fever in any 
locality points unmistakably to some imperfection in the disposal 
of sewage in that district. It may be carried by flies or other insects, 
or by dust containing dried human excreta. 

While the disease is not contagious, and cannot be spread by per- 
sonal contact, still it is true that a child ill with typhoid fever should 
be regarded as a source of infection to all those with whom he comes in 
contact, and all bed linen, articles of clothing, dishes, etc., may be 
soiled by the fecal or urinary discharges or by the sputum. These 
should be soaked in a 1 to 20 carbolic solution and boiled. The hands 
of all attendants should be dipped in a creolin solution and washed 
often, especially before eating. 

The disease is more common in temperate climates, and in the 
autumn months. During infancy both sexes are equally affected; 
in childhood boys are more exposed, consequently more cases occur 
among them than in girls. 

The typhoid bacilli are found especially in Peyer's patches, the 
mesenteric glands, and the solitary follicles of the intestines, also in 
the liver, spleen, bile, bone-marrow, and blood, as well as in the rose- 
colored rash. In the first few days of the disease they can be demon- 
strated in the stools by cultural methods. They may occasionally 
be found in the exudate of pleurisy or meningitis occurring during 
typhoid. They often remain virulent in water and milk for a period 
varying from a few days to three months — an important fact, con- 



618 THE SPECIFIC INFECTIOUS DISEASES 

sidering that milk and water form almost the exclusive diet of the 
infant. They may also remain virulent in the ground for long periods 
of time, and may not be killed by freezing temperatures. The bacilli 
are not always destroyed by the dilute acid condition of the gastric 
secretions, and may pass in a virulent state into the intestinal canal 
where they infect the system at large, and multiply in the lymphatic 
tissues. 

Pathological Anatomy. — In intra-uterine typhoid the infection is 
mainly one of the blood, and the typical intestinal and mesenteric 
lesions are absent, while in infants and children the intestinal lesions 
are usually not as marked as in adults. Peyer's patches and the 
solitary follicles are enlarged, but ulceration is uncommon, and, if 
present, is usually not deep, hence perforation seldom occurs. In 
typhoid fever the length of the ulcer corresponds with the long axis 
of the intestine, whereas in tuberculous ulceration of the bowel the 
greatest length of the ulcer is transverse in direction. Ulceration, 
if present, is more often found in the lower portion of the ileum; next 
in frequency in the upper colon, which is also the most common seat 
of perforation. The older the child the more closely do the intestinal 
lesions resemble those in the adult. The mesenteric glands are espe- 
cially apt to be involved in the vicinity of the ileocecal valve. 

Peyer's patches and the solitary and mesenteric glands may show 
only moderate inflammation and swelling; but, as these conditions 
are often found in intestinal diseases in infants and children, one can 
not assume that the case is, therefore, one of typhoid. The disease 
is often seen in children after five years of age, and but 8 per cent, 
of the cases under Hve years, while 42 per cent, are between Hve and 
eleven years, and 50 per cent, between ten and fifteen years. The 
period of incubation is from nine to twenty-one days. 

Typhoid Fever in the Fetus. — Symptoms. — If the mother has 
typhoid fever the fetus is often infected with the disease, although, 
the mother may have typhoid, and the fetus escape. Miscarriage 
occurs in more than one-half the cases of pregnant women who have 
typhoid, and the fetus is usually born dead, the death of the fetus 
being commonly the cause of the miscarriage, although the high 
temperature or the accumulation of toxins in the maternal blood may 
also cause the premature expulsion of the fetus. If the fetus is born 
alive it usually lives only a few days, quickly succumbing either as 
the result of the intra-uterine typhoid infection or because of its 
undeveloped, frail, and delicate physical condition. Occasionally a 
child, if born near the end of the pregnancy, may outlive the attack 
of typhoid. 

The typhoid bacilli may pass from the mother through the placenta 
into the fetus, although it is questionable whether they ever pass 
through a healthy placenta. 

The infection occurs through the blood, the bacilli entering the 
fetus through the umbilical vein, and the system at large being sub- 
sequently infected. The disease is practically from the beginning 



TYPHOID FEVER 619 

a septicemia, which explains the great mortality in this form of 
the disease. The typical intestinal lesions are not found; indeed, 
in the majority of cases, no intestinal lesions are present, and when 
found they are but slight. This is undoubtedly due to the absence 
of function of the bowel before birth, and to the fact that no bacilli 
enter the intestinal tract from the mouth. The spleen may be 
enlarged, the kidneys may show slight changes, and the liver may 
present the usual changes of typhoid; occasionally, slight lesions 
are found in the intestinal mucosa. The condition is, however, a 
blood infection, the typhoid bacilli being found in the spleen, liver, 
kidneys, and heart's blood. The Widal reaction may be obtained 
from the blood of the fetus. In these cases the agglutinating factor 
may have passed from the mother to the fetus. 

Typhoid Fever in the Infant. — The disease is less common in the 
first two and a half years of life than in older children, largely because 
the infant is fed either on breast milk or on certified or pasteurized 
milk. It is undoubtedly true that many cases of the disease arc over- 
looked in infants, the possibility of typhoid not being considered. 
In the older child or adult a continued fever invariably suggests the 
possibility of typhoid, and a Widal test is made. Owing to the belief 
that infantile typhoid is rare, this test has not commonly been applied 
to infants; and, while the disease is less common than in later child 
life, still those who apply this modern means of diagnosis will not 
infrequently meet with cases in infancy. 

The disease runs a shorter course in infants. Prodromata are not 
apt to be marked. Drowsiness, disturbed sleep, loss of appetite and 
indigestion are among the most common symptoms. The onset may 
be sudden, with vomiting and fever. The duration of each stage is 
usually shorter in the infant than in the child. 

The mortality in infantile typhoid is not easy to determine. In 
many of the reported cases, proven to be typhoid by a Widal, the 
disease was severe and the mortality high. If, however, many cases 
of typhoid in infants have been overlooked, and, personally, I believe 
this to be the case, then many of these cases were mild in type, which 
tends to make the prognosis more favorable. The infection in fatal 
cases in infants is general in character — not, as in older children, 
largely intestinal — and the temperature curve is not so regular and 
characteristic as in the older child and adult. 

In infants the average duration of the fever is not more than two 
weeks. Diarrhea is more common in the early part of the disease, 
and vomiting with loss of appetite is not an unusual early symptom. 
Weakness and prostration are common, but epistaxis seldom appears. 
While the infant may be drowsy and dull, convulsions are rare. The 
tongue is coated, and not apt to be dry. Sore throat occurs in a fair 
proportion of the cases. Abdominal distention is the rule. Bronchitis 
is usually present, but not severe. The pulse is often rapid and weak, 
but, as a rule, the circulation is well maintained. The infant is rest- 
less and fretful, but rarely has any other marked nervous symptom. 



620 



THE SPECIFIC INFECTIOUS DISEASES 



The fever rises rapidly, usually reaches the maximum in four or 
five days, remaining high for seven or eight days, and returns to nor- 
mal by a rapid decline or a more gradual fall in from four to seven 
days. The rash is seen in about 70 per cent, of the cases. It may 
appear earlier than in later childhood, its development on the fifth, 
sixth or seventh day being not uncommon. The spleen is usually 
enlarged, often after the fifth day. A positive Widal reaction is 
obtained in 90 per cent, of the cases. The leukocyte count is low, 
ranging from 4000 to 12,000. The urine may show albumin, and 
occasionally hyalin and granular casts, especially in the severe cases. 



D^EASE 1 2 3 4 5 C 


1 8 9 10 11 12 


13 1 


t 15 16 17 18 19 


E~ £ £ £ S £ E E E E E 


222222222222 


2 


2 


5 2 


22222222222 


o < o. < o.' <" a < a! i a < 


a'<i<i<^<^o< 


a. 


< 


a. < 


a. < qL < a < o-' ■= a.' <" a. 


105 


A 1 










§104 ir 

5 ml ' A-l 


V^ rt ^ ^ & 










S3" Ka v * 


V v 4v 


\ 




A 




uj 102 -i -j 
i- mi A-i U 






V 


\ 


^ 


i 10 ! rv 








v 


Kt\-i 


m 100 . X 

1 aS-Ai 








V 


_5_ul*— . 


< 99 J f 










— JVa 


98 










v v^ 


PULSE 120 HO 118 140 120 1 


30 115 116 140 142 116 114 


132 122 110 111 103 9G 102 


RESP. 3G 42 40 33 35 S 


7 29 34 28 36 28 34 


37 29 32 34 30 28 29 



Fig. 66. — Typhoid fever in a child two years of age. 



Typhoid Fever in the Older Child. — Fever. — The first stage shows 
a fever higher each morning than the preceding morning, and an 
evening fever higher each evening than the preceding evening. In 
the second stage the fever remains more or less continuously high, 
with a morning fall of 1.5° to 2.5°, and an evening rise of about 
the same extent. In the third stage the temperature gradually 
returns to normal, the morning temperature being lower than the 
evening, and reaching normal several days before the evening tem- 
perature. The average duration is eighteen to twenty-one days. 

In the so-called abortive cases the duration may be much less; 
yet, again, the fever may continue for four or five weeks. The usual 
height of the fever is 102° to 103° F., but high temperatures of 104° 
to 106° F. are not uncommon. Increased fever often apparently pro- 
duces no special increase in. the symptoms. The temperature may 
remain subnormal during the first two or three days of convalescence. 
A sudden and marked fall in temperature usually means intestinal 
hemorrhage or perforation. With intestinal hemorrhage the pulse is 
weak, the face pale, and the extremities cold. With perforation there 
may be localized abdominal pain which increases, also increasing 
tenderness, rigidity of the abdominal muscles, vomiting, and collapse. 

Pulse. — The pulse, as a rule, is only moderately increased, and is 
slower than in other diseases with the same temperature. It may, 



TYPHOID FEVER 



621 



however, be rapid and dicrotic. It is not as slow in proportion to the 
fever as in adults, a pulse rate of 160 to 170 not being uncommon, and 
not necessarily a sign of danger. The older the child the slower, as 
a rule, the pulse. Dicrotism is often observed. As the pulse is not 
as slow in proportion to the fever as it is in the adult it is of less 
assistance in forming a diagnosis. 

A murmur, systolic in time and heard best at the apex, is not uncom- 
mon toward the end of the third week. It is temporary in character 
and disappears after the patient has entirely recovered from the 
illness. Myocarditis may be the cause of the murmur, or it may be 
hemic. By acting on the pneumogastric centre the toxins may possibly 
affect the pulse, and by their action on the heart muscle produce the 
murmur. 



disease 1 2 3 4 5 G 7 8 9 10 11 12 13 14 15 10 17 18 19 I 20 21 22 


Q 2 2 SB » a 2 2 2 2 S 2 2 2 2 2 2 2 2 2 S 2 2 2 2 2 2 2 2 2 2 22 Z 1 1 * 2 2 2 zlz 2 2 2 2 


* A 


3— -_ A X^JjU hA-V-Vl 7 


\Z- U-U-i ^-f\j\\A%U 


C—N-4- lJJ.P_i\\ 


iZsti -- —^ 


i"-7_: iu 


98 ^ 


PULSE 100 110 IIS 120 112 IDS 124 120 100 9!? 104 112 120 10G 104 100 08 90 100 9G 94 93 


RESP. 26 30 27 28 32 24 3U 27 23 28 22 24 20 25 27 25 22 24 24 23 23 22 



Fig. 67. — Typhoid fever in a child seven years of age. 



Bowels. — Constipation may be present, especially - in younger 
children, but there is slight diarrhea in about 50 per cent, of all the 
patients. The" stools are not characteristic. Severe diarrhea is uncom- 
mon except in the worst cases, and intestinal hemorrhage occurs in 
only about 2 or 3 per cent, of the cases, and is most often seen at the 
end of the second week. The mortality after hemorrhage is about 
50 per cent. Hemorrhage is uncommon in children under ten years 
of age. 

Perforation rarely occurs, but, when this dangerous symptom 
develops, the life of the patient usually depends upon its immediate 
recognition. With perforation we have a sudden fall in temperature, 
sudden abdominal pain, and changes in the respiration and pulse. 
The pain continues, there is tenderness with some rigidity of the 
abdominal muscles, and there may be vomiting and sweating. The 
movements of the abdomen on respiration are restricted, there is 
decrease in the area of liver dulness, with movable dulness in the 
flanks, and leukocytosis. 

Abdominal distention is present in 70 per cent, of the cases, more 
often in older children. Abdominal pain and tenderness seldom appear, 



622 THE SPECIFIC INFECTIOUS DISEASES 

although vomiting is a common early symptom in the younger child. 
Diarrhea is often seen in the severe cases. 

Tongue. — The tongue is not so dry as in adults, is usually coated 
early in the disease, the edges and tip being clean. 

Rash. — Rose-colored spots appear in over 60 per cent, of the cases, 
being scattered over the abdomen, chest, back, and thighs. The 
number of spots is less than in adults. They usually develop at about 
the seventh to the ninth day, coming in crops, which last about ten 
days. They are of great diagnostic importance, and usually reappear 
in a relapse. 

Spleen. — The spleen is enlarged in almost all cases, this enlargement 
being demonstrated by palpation or percussion in about 80 per cent, 
of typhoid children. A decrease in the size of the spleen is a favorable 
sign, and usually means that the child is progressing favorably. An 
enlarged spleen that does not decrease in size indicates the continuance 
of the infection and persistence of the disease. During a relapse the 
spleen, as a rule, enlarges. 

Lungs. — Bronchitis is so often present that it may justly be con- 
sidered a normal part of the disease. Bronchopneumonia is an 
unfavorable complication, especially in delicate children and in 
hospital cases. Lobar pneumonia and pleurisy are seen occasionally; 
lung abscess is rare. 

Headache. — Headache is present in 80 per cent, of the cases, and is 
usually complained of by children old enough to describe their symp- 
toms. Vertigo is less common, appearing in about 20 per cent, of 
cases. 

The Nervous System. — Delirium in mild form is common; in the 
severe cases it may be marked. Dulness is especially apt to be seen 
in the younger children. True meningitis is rare, although a menin- 
gitis due to the typhoid bacillus may occur. Post-typhoidal temporary 
insanity occasionally develops, in the mild form is not uncommon, 
and is seen especially in those children whose nutrition is poor, and 
who take a subnormal amount of nourishment; it may also be toxic 
in origin. It usually ends in complete recovery. 

Delusions of fear are common, or the child may become greatly 
excited on the slightest cause, or may be greatly depressed mentally. 
The nervous symptoms, as a rule, improve in proportion to the possi- 
bility of increasing the child's food. Chorea and neuritis occasionally 
appear, and paralysis may develop in those muscles supplied by the 
affected nerves. 

Convulsions are dangerous and often a cause of death. Hemiplegia 
is a rare complication, but may be caused by embolism or thrombosis. 
In severe and protracted cases the mental powers may be more or 
less impaired, and melancholia, various degrees of mental excitation 
or depression, or temporary dementia may develop. The tendency 
of these conditions is to end in complete recovery, except where there 
are permanent brain lesions, as in some cases of hemiplegia. Epistaxis 
is less common than in adults, occurring in about 20 per cent. 



TYPHOID FEVER 623 

Kidneys. — Degenerative changes of mild degree probably occur in 
most cases. At the height of the disease a trace of albumin is detected 
in the urine, and occasionally a few casts. Typhoid bacilli are found 
in the urine in from 20 to 50 per cent, of the cases. Ehrlich's diazo- 
reaction in the urine occasionally appears as early as the fifth day, 
although the usual time is from the seventh to the tenth day; or 
it may not appear until the end of the fifth or sixth week, consequently 
it may appear before or after the Widal. It is absent in about 15 per 
cent, of all cases. 

Blood. — The leukocytes are reduced in typhoid fever, leukopenia 
being the rule. In 10 per cent, of the cases the white cells are 5000 
or less; in 70 per cent., 5000 to 10,000; in :',() per cent., 10,000 to 
10, 000. If leukocytosis exists, it is usually due to some complication. 
As the disease progresses secondary anemia develops, both the red 
cells and the hemoglobin being diminished, and during convalescence 
the red cells return to the normal more rapidly than docs the hemo- 
globin. 

Blood cultures are of great assistance in a case of doubtful diagnosis. 
The younger the child the more difficult it is to locate and puncture 
the vein, but those who have mastered the technic have comparatively 
little trouble in obtaining from \ to 2 c.c. of blood by puncturing a 
vein in the arm. Busquer recovered the typhoid bacillus in 43 chil- 
dren he examined, and Rotch and Conrodi have also proven the 
efficacy of this means of diagnosis. The Widal reaction is of great 
diagnostic importance, and is present in 95 per cent, of children with 
typhoid fever. It is present in 13 per cent, by the seventh day; in 
63 per cent, by the fifteenth day; and in 89 per cent, by the twenty- 
fifth day. Occasionally it is not present until the patient is entirely 
free from all typhoid symptoms. In children with jaundice there is 
a positive Widal, hence in a case of jaundice the Widal loses its 
significance. 

Relapses. — The number of relapses varies in different epidemics. 
In some years it may be only 4 per cent., in others, 15 per cent. In 
my own cases it has been 9 per cent. The duration of the relapse 
is usually about fifteen days; ordinarily it is shorter than the original 
attack. In a relapse the spleen is enlarged, the roseola is present in 
75 per cent, of the cases, leukopenia in 60 per cent., and mild intestinal 
symptoms in about one-half the cases. 

Diagnosis. — In the diagnosis of a doubtful case of typhoid fever, 
the temperature, rose spots, enlarged spleen, Widal reaction, blood 
cultures, Ehrlich's diazo-reaction, typhoid bacilli in stools and urine, 
and the intestinal symptoms, are all worthy of careful study. Usually 
the diagnosis is easy, occasionally it is difficult, but it is almost always 
possible to decide positively whether typhoid is present or not. 

Differential Diagnosis. — Appendicitis. — A child may be taken sud- 
denly ill with severe pain in the right iliac fossa, high fever, vomiting, 
and often little or no resistance of the abdominal walls. The early, 
subsidence of the symptoms in the region of the appendix, the appear- 



624 THE SPECIFIC INFECTIOUS DISEASES 

ance of rose spots, enlarged spleen, and a positive Widal clear the 
diagnosis. Yet in a case of typhoid fever, a typhoid ulcer in the 
appendix may cause a perforation. 

Paratyphoid Fever. — The symptoms are very like those of typhoid 
fever, but usually less severe and of shorter duration. The paratyphoid 
bacillus, which may be found in the stools, urine, and blood, differs 
only slightly from the typhoid bacillus, and an agglutination of 
paratyphoid cultures occurs with the blood of the child with para- 
typhoid. There is no Widal reaction. 

Acute Miliary Tuberculosis. — In this disease the onset is slower 
than in typhoid. There may be a family history of tuberculosis, or 
a history of the child's exposure to tubercular infection. A preced- 
ing pneumonia, pertussis, or measles, with incomplete recovery is 
suspicious. Cough, irregular fever, and nervous symptoms may be 
present in both, and in miliary tuberculosis the physical signs in the 
lungs are not usually significant. 

The presence of tuberculous lymph glands, a persistent cough, grad- 
ually increasing physical signs in the lungs, the appearance of tubercles 
in the choroid, a positive tuberculin test, and the finding of tubercle 
bacilli in the mucus removed from the pharynx, will confirm the 
diagnosis of tuberculosis. A positive Widal, rose spots, and typhoid 
bacilli in the stools, urine, or blood make certain the diagnosis of 
typhoid. 

Prognosis. — The mortality varies in different epidemics according 
to the severity of the infection, the general health and vitality of the 
child, and whether it comes under observation early or late in the 
disease. In hospitals the mortality-rate is about 8 per cent.; in 
private practice 4 per cent. The prognosis is, of course, influenced 
by all complications, in direct proportion to their mildness or severity. 
In my experience, most of the deaths were associated with complica- 
tions, such as bronchopneumonia, hemorrhage, or perforation. The 
prognosis is really better than is apparent from statistics, as mild 
cases of typhoid are easily overlooked. A continued fever in a child 
should always suggest the possibility of typhoid fever, and a system- 
atic examination for typhoid in all such cases is the only method by 
which one can avoid error. 



Number of Deaths in Philadelphia- 


-Typhoid 


Fever. 




Age period. 


1911. 1912. 


1913. 


1914. 


1915 


Under 1 year 














1 to 2 years 


4 3 


2 


1 





2 to 5 " . . 


10 7 


10 


5 


2 


5 to 10 " 


14 7 


13 


8 


5 


10 to 15 " 


15 18 


17 


12 


13 


15 to 20 " . . 


24 29 


26 


17 


19 


All ages .... 


223 200 


255 


124 


109 



Complications. — Among the more common complications may be 
mentioned otitis, pneumonia, diphtheria, hemorrhages, furunculosis, 
and nephritis. Among the rarer complications are measles, scarlet 



TYPHOID FEVER 625 

fever, gangrene of the skin, chorea, and neuritis. Aphasia is more 

common in children than in adults, and usually appears in the third 
week in severe cases associated with nervous symptoms. It ordinarily 
ends in complete recovery in three or four weeks. Meningitis may be 
due to the typhoid bacillus, and may end in recovery. 

Treatment. — Prophylaxis is of the greatest importance; and, as the 
drinking of infected water is the most common cause of the disease, 
it is wise to order that all drinking water, and water used for washing 
such vegetables as celery or cress, be boiled. If a case of typhoid 
fever exists on a dairy farm, milk from such a farm should not be 
allowed to be sold. An infant should be weaned if its mother has 
typhoid, and all children who are apt to be exposed to typhoid fever 
infection may be protected by typhoid vaccine. The feces and urine 
of a typhoid child should be disinfected by covering them with three 
times their bulk of 1 to 20 carbolic acid, or 1 to 1000 bichloride 
solution. 

All dishes, spoons, etc., should be similarly treated with 1 to 20 
carbolic acid, and all bed linen should be soaked in 1 to 20 carbolic 
solution, and then well boiled. All typhoid cases should, if possible, 
be kept apart from both well and sick children, as it is not uncommon 
for those who handle, nurse, or come in intimate contact with typhoid 
cases to contract the disease. The hands of the nurse, especially, 
are in danger of being contaminated by the fecal or urinary discharges, 
and infection thus take place; therefore, the hands of all who come 
in contact with typhoid cases should frequently be washed in a solu- 
tion of lysol, 1 to 200, particularly before eating. 

The child should be kept in bed, in a large, well- ventilated room, 
until the temperature has been normal for a week. 

Diet. — Nourishment should be given every three hours during the 
day and every three or four hours during the night. The nourish- 
ment should be liquid, milk being the best single article of diet, and 
this should be administered in such quantities and such dilutions as 
the child can digest. It may be diluted with water, or barley-water, 
and x if not well digested, should be peptonized. If the symptoms of 
gastro-intestinal infection are present, milk is contra-indicated until 
the acute symptoms have subsided. 

Mutton, beef, and chicken broths may be given in addition to the 
milk, and albumen-water is often well borne and answers a useful 
purpose. A raw egg, either alone or beaten up with milk, is very 
nourishing, especially in the early stages of convalescence. Cereal 
gruels, thoroughly cooked and well thinned with milk, may be given 
throughout the illness. 

If the disease runs the regular course of about three weeks, milk, 
animal broths, and cereal decoctions with milk are all that is required. 
If, however, the fever continues for four, five, or six weeks, yet no 
relapse has occurred, and especially if there is extreme prostration 
with emaciation, but no marked symptom of gastro-intestinal infec- 
tion, raw eggs, or soft eggs, junket, and custards may be added to the 
40 



620 THE SPECIFIC INFECTIOUS DISEASES 

diet. After the temperature has been normal for one week, milk toast, 
scraped meat, zweibach, and soft foods may be allowed. Water 
should be given freely throughout the disease. 

Hydrotherapy. — If the child's temperature remains below 103° F., 
a morning and evening sponge with water at 90° F., followed by an 
alcohol rub, is all that is required. The best method of treating 
pyrexia and the associated nervous and respiratory disturbances is 
by the bath. The temperature of the water should be 90° to 85° F., 
and the child should remain in the tub, its entire body, except the 
head, being covered by the water, from five to twelve minutes. Fric- 
tion of the body and sponging of the head should be kept up throughout 
the time of the bath. 

The length of the bath depends upon the effect produced on the 
temperature, and the nervous and respiratory symptoms. After the 
bath the child should be well rubbed and returned to its bed. The 
rectal temperature should be taken ten minutes after the bath, and 
the reduction in the fever will serve as a guide in deciding upon the 
duration of future baths, and the temperature of water to be employed. 
If there is prostration, whisky, in doses appropriate to the age of 
the child, may be given before and after bathing. 

The bath should be repeated every three to six hours if the tem- 
perature remains at 103° F. or higher, and an ice-cap applied to the 
head is often beneficial in those cases where the temperature remains 
high and the nervous symptoms marked. Bromide of soda, 5 grains, 
repeated in three hours if necessary, is of assistance in quieting the 
nervous symptoms and inducing sleep. Cold-water baths are not 
well borne by children with typhoid, and, in my experience, the water 
should never be below 80° F. 

Bowels. — During the first few days of the disease constipation may 
be overcome by fractional doses of calomel, and while the fever con- 
tinues it may, if marked, be partially relieved by an occasional dose 
of castor oil. The safest and best means of overcoming this condi- 
tion is by the daily use of an enema of salt solution, soap and water, 
or small amounts of sweet oil. If the number of stools in twenty-four 
hours exceeds four, especially if they are large and watery, it is well 
to control the diarrhea by subnitrate of bismuth, 5 to 10 grains, every 
three or four hours, and in older children, 1 to 2 grains of salol may be 
added to each bismuth dose. The bismuth and salol are only to be 
given as long as the diarrhea continues. Paregoric, 10 to 20 drops, 
may be given in addition to the bismuth if the diarrhea is not easily 
checked, the dose being in proportion to the age of the patient and 
the severity of the diarrhea. 

The stools should always be carefully examined, as the presence of 
undigested food materials may be of service in the selection of the 
diet to be given. Tympanites is best controlled by a hot turpentine 
stupe applied to the abdomen and covered by oiled silk and the giving 
of a warm enema of salt solution. If this does not afford relief, a 
rectal tube may be cautiously used. 



PARATYPHOID FEVER 627 

Alcohol. — Whisky is not required in the mild eases. In the asthenic 
cases whisky, 20 drops to 1 dram, may be given every three hours; 
it is especially valuable when there is low muttering delirium and a 
weak pulse. Strychnine and camphor are of benefit when the heart- 
sounds are weak, or if a murmur develops due either to changes in 
the myocardium or to general toxemia. 

Hemorrhage from the bowel demands absolute rest for the patient, 
an ice-coil to the abdomen, sufficient opium by the mouth to check 
intestinal peristalsis and bowel movements, the stopping of all food, 
and the giving of only small pieces of ice or very small amounts of 
water by mouth. Parotitis is best treated by the application of an 
ice-bag. Perforation demands the opening of the abdomen, and the 
closing of the perforation in the intestine. An early diagnosis of per- 
foration is essential if the child's life is to be saved. 

PARATYPHOID FEVER. 

Paratyphoid fever in many cases bears a close resemblance clinically 
to typhoid fever, but it is due to an entirely different organism. In 
paratyphoid there are no intestinal lesions. 

Etiology. — The organisms which cause the disease are called para- 
typhoid bacilli, and are divided into two groups, "A" and "B," 
according to their cultural characteristics. Many cases of paratyphoid 
fever are the result of food poisoning, and there is considerable evidence 
also to show that it is a water-borne disease. 

Symptoms. — The symptom-complex is practically the same as in 
typhoid fever; the disease may occur in epidemics, and is not uncom- 
mon. It may be differentiated from typhoid fever by a negative 
Widal reaction which, however, is only obtained when the tested 
blood is diluted more than 1 part in 50. The paratyphoid organisms 
cause an agglutinin reaction, but belong, according to their cultural 
and other characteristics, between the typhoid bacillus and the 
Bacillus coli communis. The symptoms are usually less severe than 
in typhoid, but one may observe nosebleed, headache, and anorexia; 
the temperature may be about 101° F. at first, and so continue for 
two weeks, rising a degree, to 102° F., every day, and falling the 
next morning. In some cases the symptoms closely resemble Asiatic 
cholera, and there is little, if any, evidence to suggest typhoid. The 
spleen is usually enlarged, but Peyer's patches, the mesenteric glands, 
and solitary follicles are not involved. In the worst cases the symptoms 
are largely those of septicemia. 

Diagnosis. — The diagnosis is made by examination of the blood, 
which gives a positive agglutination reaction with the paratyphoid 
bacillus. 

Prognosis. — The prognosis is usually favorable, and death occurs 
only in the most severe cases. 

Treatment.— The treatment is, for the most part, the same as in 
typhoid fever. 



628 THE SPECIFIC INFECTIOUS DISEASES 

SCARLET FEVER (SCARLATINA). 

Scarlet fever is an acute contagious disease, occurring sporadically 
or in epidemics. It is characterized by sudden onset, sore throat, 
a punctate eruption, scarlet in color, which covers the entire body, 
and is followed by desquamation of large flakes of superficial skin. 
There is a tendency to otitis, cervical adenitis, and nephritis. 

Etiology. — The disease is essentially one of children. It is rarely 
met with in infants under six months of age, and is uncommon even in 
children from six to twelve months. Numerous instances have been 
reported where the mother having scarlet fever continued to nurse 
her infant under six months of age, and the child did not contract the 
disease. 

A very few cases of infants being born with scarlet fever are on 
record, the mother having the disease at the time of the infant's 
birth. After the age of one year the susceptibility to the disease 
increases with each year until the extreme is reached at five or six 
years; after this age the number of cases gradually decreases and it 
is uncommon after the sixteenth year. It is occasionally seen in adult 
life, but after the period of childhood is passed the disease is usually 
in a mild form. 

In Philadelphia during the years 1911 to 1915 inclusive only 18 
deaths occurred from scarlet fever in children under one year of age. 
More than 60 per cent, of the cases occur in children under lave years 
of age, and 90 per cent, in the first ten years of life. Unlike measles, 
immunity in adult life does not depend upon the fact that most 
children contract the disease, as it is estimated that not more, and 
probably less, than 50 per cent, of children have scarlet fever. 

Second attacks are rare. Family predisposition to contract scarlet 
fever is occasionally observed, and not only may all children in the 
family contract the disease, but it may appear in them in a most 
severe form, while the other cases seen at the time may be of quite 
a mild type. It is more common in the winter months, possibly because 
children are kept indoors more, and are brought more often and more 
closely in intimate contact. 

Epidemics differ greatly in severity and in the liability to dangerous 
complications. It is more common in city than in country districts, 
and the white race is more susceptible and shows a greater mortality 
than the colored race. 

The specific virus of scarlet fever is as yet unknown. The immunity 
that one sees so often in those exposed to scarlet fever is not always 
permanent, as a child who has been brought in close contact with 
a scarlet fever patient may, if afterward exposed, contract the dis- 
ease. The virus is present in the discharge from the nose, mouth, 
and ears, and while this dried discharge containing the poison may be 
carried for short distances by the air, it cannot be carried far, as 
those children living in the neighborhood of scarlet fever hospitals 
do not show any unusual tendency to contract the disease. 



SCARLET FEVER 629 

Scarlet fever has been produced in children by inoculation with the 
mucus from the mouth and throat, also by the blood and contents 
of the vesicles, so that undoubtedly the virus producing the disease 
must be present in these fluids. 

It is still a matter of doubt as to whether it is possible to produce 
scarlet fever by inoculating a child with the scales; the evidence is 
against the possibility and probability of the disease being trans- 
ferred by such inoculations. The poison lives for long periods of 
time outside the human body, and may remain virulent and cling 
to the bed linen, carpets, wall paper, and any portion of the room 
for months, in spite of the most thorough .Scrubbing, disinfecting, and 
flushing with fresh air. 

The disease is usually spread by direct personal contact. The 
mild cases are especially to be feared as sources of infection, as they 
may not be ill enough to go to bed, and may even continue to attend 
school; they are consequently brought in close contact with a large 
number of well children, and may easily transmit the disease. 

Epidemics have been traced to milk, and boiling the milk destroys 
the scarlet fever poison. AVhile the lower animals do not contract 
the disease, a pet cat or dog may carry the poison from the sick-room 
to children in the same or near-by house. 

The disease may be carried by a third person, and all persons 
coming in contact with a scarlet fever patient, especially the nurse 
and physician, should take definite precautious to avoid carrying the 
infection. Numerous instances have been reported where the disease 
has been known to be conveyed considerable distances by letters 
or packages sent by mail. 

The scarlatinal poison enters the body through the nose and throat ; 
less often through wounds and burns, and in puerperal women 
through the genital tract, although it is certain that many of the 
so-called cases of scarlet fever in puerperal women have been puer- 
peral sepsis and not scarlet fever. 

The streptococcus is, by some, considered the cause of the disease, 
and streptococci have been found in the blood, skin, and in the internal 
organs at autopsy. The general belief is that while the streptococcus 
may and often does exist as a mixed infection, and does produce 
many of the dangerous symptoms and complications of scarlet fever, 
as pseudomembrane in the pharynx, otitis, cervical adenitis, endo- 
carditis, synovitis, and nephritis, that it is present only as a compli- 
cation, and is not the true cause of the disease. 

A protozoon has been found in the skin by Mallory, and the belief 
that the disease is caused by a protozoon is steadily growing in favor. 
The contagion is slight in the beginning of scarlet fever, whereas 
in measles the contagion is marked from the very beginning of the 
disease. Scarlet fever is very contagious during the eruption and 
for quite a long time after the eruption has disappeared, but it is 
not at all certain that the contagion is due to the skin that is peel- 
ing off; in fact many believe that this desquamating epidermis is 
incapable of producing the disease. 



630 THE SPECIFIC INFECTIOUS DISEASES 

A scarlet fever patient can transmit the affection before desquama- 
tion begins and after it has ceased, and a discharge from the nose, ear 
or throat persisting after desquamation has ceased is a not uncommon 
source of infection. Nothing is more common than for a scarlet 
fever patient to be released or escape from quarantine before desqua- 
mation is complete, and as the general belief at present is that the 
contagion is contained in the scales, a child who is desquamating 
would, if the scales carry the contagion, expose to the disease all those 
with whom he comes in contact. 

The disease is especially contagious when the fever is high, and the 
throat symptoms severe, and is more or less contagious as long as 
any discharge is present from the nose, ears, or throat, and until 
desquamation is complete, and quarantine in an ordinary case should 
continue for six weeks. Infected articles and clothes that have been 
kept in closed drawers and closets may transmit the disease months 
or even years later. 

Measles, whooping-cough, chicken-pox, diphtheria, typhoid fever, 
or erysipelas, may coexist with scarlet fever, although a pseudomem- 
brane in the pharynx or larynx may be diphtheritic or streptococcic. 
It is estimated that from 2 to 4 per cent, of the scarlet fever cases 
discharged from the hospital transmit the disease to other children. 
This estimate I believe is too small. 

Pathological Anatomy. — In an uncomplicated case of scarlet fever 
pathological changes are found in the skin, tongue, throat, and the 
lymphatic glands. The rash disappears after death, except in those 
locations where it has been especially marked during life. If the 
rash is of the hemorrhagic form it is visible postmortem. 

The skin shows a marked congestion of the bloodvessels, and a 
dilatation of the lymphatics with moderate cellular proliferation 
around the bloodvessels, hair follicles, and sweat glands. The 
epidermis is destroyed and is later thrown off in scales or flakes. The 
tongue shows similar changes in its epithelium to that occurring in 
the skin, but the changes occur earlier in the disease and are more 
severe. The pharynx shows an inflammation which may be of a mild 
catarrhal form, or of a severe type with pseudomembrane. 

The anterior and posterior nares show a more or less severe 
involvement of the mucosa, and the ears are not infrequently involved. 
The infection may extend from the nose to the antrum of Highmore 
or from the ear to the mastoid with possible involvement of the 
meninges, and later of the brain. 

The lymphatic system throughout the entire body is involved to 
a marked extent in scarlet fever. Not only are the superficial 
lymphatics, as the cervical, axillary and inguinal, enlarged, but the 
deeper glands, as the tracheal, bronchial, mesenteric, and retro- 
peritoneal, are also affected, and the tonsils, liver, and spleen show 
a distinct hyperplasia. The cervical lymphatics may undergo sup- 
puration, and the infection may spread to the surrounding tissues, 
resulting possibly in abscess, and rarely gangrene. 



SCARLET FEVER 631 

In severe cases the mucous membrane of the stomach shows 
distinct inflammatory changes and similar changes are found in the 
mucous membranes of the intestine with marked swelling of the 
lymph follicles. 

The heart may show either cloudy swelling or fatty degeneration; 
less commonly, an endocarditis or pericarditis develops. Hypertrophy 
and dilatation may ensue from a nephritis. Bronchopneumonia is not 
uncommon in the fatal cases and a seropurulent pleurisy, pulmonary 
gangrene, and abscess may occur. Acute interstitial nephritis is the 
most common form of nephritis associated with scarlet fever, and in 
all fatal cases more or less marked pathological changes in the kidneys 
are found. 

Symptoms. — The period of incubation is short, usually from one 
to seven days; commonly the disease develops within two to four 
days after exposure. The shorter the incubation, the more severe 
is, as a rule, the attack. 

Stage of Invasion — The child is taken suddenly ill without any 
prodromes; vomiting is often the first symptom. The vomiting may 
occur a number of times and be very severe. In young children, a 
convulsion is not uncommon, and very occasionally the disease may 
begin with a chill. Fever is present from the first, and usually reaches 
its maximum in twenty-four to forty-eight hours and may even in 
a few hours rise to 104° or 105° F. The higher the initial fever, the 
more severe, as a rule, is the illness, although in the mild cases the 
temperature may not exceed 101° F. 

Sore throat is an early symptom, but as many children will not 
complain of soreness in the throat, even when a considerable amount 
of inflammation is present, it is always necessary and advisable to 
make an examination of the pharynx. The severity of the inflam- 
mation, which commonly involves the soft palate, tonsils, and 
pharynx, with small red points on the hard palate, is in direct pro- 
portion to the severity of the infection. 

Headache is also an early symptom, and the severity of these 
initial symptoms, as convulsions, vomiting, fever, sore throat, and 
headache, will usually be sufficient to indicate the probable severity 
or mildness of the future course of the disease. 

The tongue is coated, the tip and edges being red, the child refuses 
nourishment, complains of thirst, is restless, drowsy, or delirious, 
and passes only small amounts of high-colored urine. In younger 
children, especially in hot weather, diarrhea may occur. 

Stage of Eruption. — The rash appears first on the neck and chest, 
and rapidly spreads over the body and face; ordinarily the entire 
surface of the body is covered in twenty-four to thirty-six hours after 
its first appearance. The rash may appear on the face only as a 
flush, or the face may be almost or quite free from rash. The eruption 
usually appears in the first twenty-four to forty-eight hours, although, 
rarely, its appearance is delayed until the third, fourth, or fifth day. 

It appears first as very small red points, set very closely together; 



632 THE SPECIFIC INFECTIOUS DISEASES 

the points are larger and not so close together on the legs. The rash 
areas are scattered in patches over the body, and, spreading quickly, 
cover the entire surface. The general color of the skin is red, and 
the appearance of the red skin and innumerable fine, darker red 
points is very characteristic. The color of the skin is usually a dull 
red, and becomes dusky red as it fades. 

The body has the appearance of being covered with a rash of 
uniform reddish color, but close inspection reveals the skin to be a 
lighter red, and the fine points to be distinctly darker. Irregular 
patches of skin on the buttocks, arms or legs, may be entirely free 
from rash, giving the skin a blotchy appearance not unlike measles. 

The face may be entirely free from rash, but usually the forehead 
and cheeks are flushed. The lips, also alse and tip of the nose, are, 
as a rule, free from rash, giving the so-called white rim around the 
mouth which is quite characteristic. The rash disappears on pressure, 
is usually accompanied by itching, and, if severe, edema and swelling 
are present. 

In the mild cases, the rash may be very slight, may only appear 
over very small areas, may not even show itself on the face, is most 
often under such conditions seen in the axillae, groins, the back of 
the thighs or buttocks, and in these locations may last for only twenty- 
four hours. The eruption continues at its height for twelve to forty- 
eight hours, and lasts usually from three to seven days. 

A careful examination of the skin will show small vesicles to be 
present in a fair proportion of cases, and especially when the rash 
has been very severe. In the worst cases the rash often varies, not 
only in its appearance, but also in the time of its development. It 
may be of a dark, almost purple color, or again it may closely resemble 
the rash of measles. If the eruption is very faint, a hot bath may 
cause it to better develop. 

Stage of Desquamation. — Usually within forty-eight hours after the 
rash has disappeared, desquamation begins. It appears, as a rule, first 
on the neck and chest, and the entire body with the exception of the 
hands and feet continues to shed fine bran-like scales for about two 
or three weeks. The peeling appears later on the hands and feet, 
the thicker skin of the palms, fingers, soles and toes being slower 
to separate, and the desquamation continuing for a longer period of 
time, usually about four or five weeks, and often peeling off in large 
flakes. Occasionally the thickened epidermis of the fingers or palms 
may separate in one large piece like the ragged finger or palm of a glove. 

The character of the desquamation is often, but not always, in 
direct proportion to the intensity of the rash, being quite extensive 
and flaky in the severe, and slight and bran-like in the mild eruption. 
In the very light cases, desquamation should be looked for at the tips 
of the fingers, under the nails, and in the groins and axillae. Desqua- 
mation may occur twice in one or more portions of the body, prolonging 
the period of quarantine. Falling of the hair and shedding of the 
nails are occasionally seen. 



SCARLET FEVER 633 

Desquamation is the most typical sign of scarlet fever, and it is 
not uncommon in hospital dispensaries or among the poor to see 
a child in the peeling stage of scarlet fever, the history being that 
a mild and transient rash occurred several weeks previously; with 
this history and desquamation, scarlet fever can be positively 
diagnosed. In very few diseases is such a great variation seen in 
the severity of the symptoms as appears in scarlet fever. Sudden 
onset, fever, sore throat, and rash are present to a greater or less 
degree in every case, but in the light cases these symptoms may be 
very mild and even pass unnoticed. 

Diagnosis. — Frank typical scarlet fever oilers no great difficulty in 
diagnosis, since it can easily be made from the presence of the more 
prominent symptoms, such as a sudden onset accompanied by vomit- 
ing, a rapid rise in temperature, the appearance of the throat, enlarged 
papilla? on the tongue, and the typical eruption appearing within 
forty-eight hours. These symptoms constitute an unmistakable 
syndrome, but no one symptom is pathognomonic. 

A diagnosis can rarely be made before the eruption appears; on 
the other hand, the diagnosis cannot be made upon the appearance 
of the rash alone, since many other eruptions resemble that of scarlet 
fever, such as the rash in rotheln, diphtheria, septic erythema, and 
influenza, also the drug rashes and antitoxin rash. 

Scarlatiniform erythemas and rashes are also produced by severe 
burns, intestinal auto-intoxication, measles, varicella, variola, and vac- 
cinia, also in rheumatism, pyemia, malaria, and typhoid fever. 

In attempting to decide whether a rash is that of scarlet fever or 
not, the time of its onset and its persistence are important points, 
and the amount of scaling which follows a rash of given intensity is 
greater in scarlet fever than after any other rash which might simulate 
it. Many eruptions cause desquamation, some more freely than scarlet 
fever; but well-marked desquamation after an illness which simulates 
scarlet fever is a point of great diagnostic value. 

In making a diagnosis after the eruption has faded or changed, 
a white line at the junction of the finger with the nail showing begin- 
ning desquamation is of great value. Another important clue to the 
diagnosis is an accurate history of the diseases the child has previously 
had and the diseases to which it has been exposed. 

Differential Diagnosis. — While the throat involvement in scarlet 
fever may suggest diphtheria at first, yet the eruption which appears 
usually indicates the true nature of the disease, and the prevalence 
of one or the other of these diseases is also confirmatory. The diag- 
nosis of diphtheria can, as a rule, be made with absolute certainty 
by a culture from the throat, and this test should always be made 
when there is any doubt. 

Measles. — The typical eruption of scarlet fever does not resemble 
the rash of measles, and when the differentiation between scarlet 
fever and measles is rendered obscure by an atypical rash, we must 
bear in mind what a wide difference there is in the other symptoms 



634 THE SPECIFIC INFECTIOUS DISEASES 

of these two affections, and this will usually permit us to make a 
definite differential diagnosis. The onset of scarlet fever is more 
severe, the fever higher, the attacks of vomiting more frequent, 
and the rash appears earlier than in measles; while photophobia, 
coryza, cough, and hoarseness are peculiar to rubeola. Sore throat, 
strawberry tongue, and cervical glandular enlargement are character- 
istic of scarlatina, and the Koplik's spots of measles are absent. 

Rubella. — The eruption of German measles resembles that of 
scarlet fever more closely than does that of rubeola; but, as a rule, 
it is not followed by desquamation, and there are no severe throat 
symptoms. The constitutional disturbances are much milder in 
rubella than in scarlatina, and the course of the disease is shorter. 
In German measles the posterior cervical glands are enlarged. 

Drug Rashes. — The various drug rashes may be diagnosed from 
the history and other untoward symptoms which appear with the 
rash. In acute exfoliative dermatitis there are no throat symptoms 
and the tongue lacks the appearance so characteristic of scarlet fever. 

Complications. — Acute nephritis is the most common complication 
of scarlet fever, and usually occurs in the second, third, or fourth 
week, after desquamation is more or less complete. A slight albumin- 
uria often appears at the height of the fever, but does not signify 
acute nephritis, or predispose to it, although the cells lining the 
tubules are at this time in a state of cloudy swelling. 

The nephritis of scarlet fever is in all probability caused by the 
specific toxin or bacillus, and the frequency with which this inflam- 
mation of the kidneys occurs in scarlet fever is to be attributed to 
the increased work thrown upon the kidneys because of the impair- 
ment of the function of the skin. Acute parenchymatous nephritis 
is the most common form of the kidney affection, but intersitial 
nephritis also occurs. The majority of cases progress favorably, 
although the disease may appear in all degreees of severity. 

Throat. — Scarlatinal angina is a very common complication, and 
is the result of streptococcic infection of the throat. It differs from 
diphtheria in that it rarely spreads to the larynx or causes paralysis. 
True diphtheria, however, is occasionally associated with scarlet fever. 

If the non-diphtheritic membrane seen in scarlet fever shows a 
tendency to spread, it may prove a source of danger by extending 
into the nasopharynx and along the Eustachian tube to the middle 
ear. Swallowing may become both difficult and painful; irritating 
discharges may exude from the nose; the breath is foul. Ludwig's 
angina may appear. Gangrene of the tonsils and ulceration may 
occur, and sometimes involve the uvula, fauces, and pharynx. 

In severe cases the cellular tissues of the neck become infiltrated 
and slough or suppurate, occasionally causing hemorrhages from the 
tonsils or vessels of the neck, and thrombosis of the jugular vein. 
Death may ensue from hemorrhage or from septicemia. In these 
cases the constitutional symptoms are all aggravated, while asthenia, 
cachexia, and, eventually, collapse precede the fatal termination. 



SCARLET FEVER ■ 635 

In the rare cases in which the larynx is involved edema of the glotti> 
occurs, and, if there be suppuration in the throat, the pus may pass 
into the mediastinum and neighboring structures, setting up puru- 
lent pleurisy and pericarditis, with symptoms of embolism, throm- 
bosis, or septicemia, and usually terminates fatally. 

Ears. — The ears become involved in scarlet fever by extension 
from the throat along the Eustachian tubes. This occurs more 
frequently in younger children, and causes the usual symptoms of 
otitis media, such as earache, restlessness, and a rise in temperature, 
with congestion and bulging of the drum membrane, which, in the 
majority of cases, eventuates in perforation of the tympanum. 
When the drum membrane is resistant, and rupture is delayed, 
mastoiditis and meningitis may supervene. It is estimated that 10 
per cent, of chronic deafness is due to scarlatinal otitis, which in very 
young children may produce deaf-mutism. 

Lymph Nodes. — The submaxillary glands are always enlarged in 
scarlet fever, and when the throat symptoms are severe there is con- 
siderable swelling of these and of the cervical lymph nodes. Suppura- 
tion may take place, or the inflammation may not proceed beyond the 
acute inflammatory stage. 

Joints. — Scarlatinal arthritis may appear early in the disease, 
and in these cases the inflammation is migratory, affecting the same 
joints which are commonly involved in adults who have acute inflam- 
matory rheumatism. These cases simulate acute inflammatory 
rheumatism, and respond to treatment with the salicylates, but are 
regarded as scarlatinal. Occasionally a less transient arthritis, which 
is septic in origin, appears late in the course of scarlet fever, and 
involves one or several joints. 

Nervous System. — Among the occasional complications of scarlet 
fever are convulsions and meningitis. Chorea and hemiplegia are 
quite rare, and but few cases of paralysis have been reported as 
following searlatina. 

Heart. — Transient murmurs are not infrequently heard during 
the course of scarlet fever, and of these the mitral systolic is the 
most common. There is often extreme irregularity of the heart's 
action, and a "bruit de galop" is occasionally heard. Transient mur- 
murs are thought to be due to a loss of cardiac muscular tone, and 
consequent imperfect closure of the heart valve. 

Acute dilatation of the heart may take place during the height 
of the fever, and endocarditis and pericarditis occasionally appear. 
Cases of malignant endocarditis are less numerous than would be 
expected from the virulence and wide-spread action of the infecting 
organism, and it is evident that the heart is affected more by scarla- 
tinal toxins than by the germ which produces the disease. 

Lungs. — Pneumonia is one of the early complications of scarlet 
fever, and may be either lobular or lobar in type; but pulmonary 
complications are not as frequent or as severe as in measles. A septic 
or aspiration pneumonia (bronchopneumonia) is liable to occur in the 
severe septic anginal cases. 



636 



THE SPECIFIC INFECTIOUS DISEASES 



Miscellaneous. — Among the various other complications of scarlet 
fever may be mentioned the following: Gastro-intestinal disturbances 
in which vomiting is a marked feature, hyperpyrexia, osteomyelitis, 
ophthalmia, and other infectious diseases of which diphtheria, measles, 
and varicella are the most common. 

Prognosis. — The prognosis in scarlet fever depends upon the char- 
acter of the epidemic, the prevalent type of the disease, the age 
of the patient, and the presence or absence of complications. When 
cases are isolated and skilfully treated from the onset of the disease, 
the prognosis is usually favorable and the mortality is not high except 
in very young children. In severe cases the prognosis should always 
be guarded, and persistent albuminuria, profuse diarrhea, and marked 
angina or otitis are danger signals. 

The hemorrhagic form is always serious, affections of the endo- 
cardium or pleura may prove fatal, and nearly all of the malignant 
septic cases die. A child with scarlet fever should not be pronounced 
out of danger until after the fourth week has passed with no compli- 
cations. 

Number of Deaths in Philadelphia — Scarlet Fever. 



Age period. 


1911. 


1912. 


1913. 


1914. 


1915. 


Total 

mortality 

for five years. 


Per cent, of 
mortality com- 
pared with 
mortality at 
all ages. 


Under 1 year . 


7 


3 


3 


4 


1 


18 


3.0 


1 to 2 years . 


19 


8 


13 


no data 


no data 




8.8 


2 to 5 " . 


85 


55 


71 


60 


8 


279 


45.0 


5 to 10 " . 


39 


34 


54 


34 


4 


185 


27.1 


10 to 15 " . 


7 


6 


9 


5 


3 


30 


5.0 


15 to 20 " . 


7 


1 


2 


4 


2 


16 


2.6 


All ages 


179 


113 


162 


129 


25 


608 





Treatment. — Prophylaxis is an exceedingly important part of the 
treatment in scarlet fever, the organism and infectious principle of 
the disease being so difficult to exterminate. The patient should 
be isolated as soon as the diagnosis is made, and strict quarantine 
maintained. 

If several children in the same house are affected, each child should 
be assigned to a separate room, or reinfection may occur. The sick- 
room should be one that can be isolated completely, and every port- 
able object should be removed from the room except those absolutely 
needed. All the children in the family should be kept from school, 
and contacts who have angina should not be allowed to mingle with 
well persons. 

Sheets soaked in a 1 to 2000 bichloride solution should be hung in 
front of the door of the sick-room, and all bed linen and clothing used 
by the patient should be soaked in a 1 to 5000 bichloride solution before 
being sent to the laundry, then boiled and sun-dried. Clothing of the 
nurse or attendant should be washable, and she should wear a close- 
fitting cap to prevent the hair from becoming contaminated. She 



SCARLET FEVER i,;7 

should also spray her throat twice daily with 1 to 5 glycothymoline 
solution, liquor alkalinus antisepticus, or with hydrogen peroxide. 

The attending physician should never enter the sick-room without 
removing his coat and vest and donning a linen gown and close-fitting 
cap. At the termination of his visit he should remove trie robe and 
cap just outside the sick-room, disinfect his hands and face, and go 
home to change and air his clothes before visiting other patients. 

The sick-room should be thoroughly disinfected after the patient 
is convalescent before it can again be used, and the mattress had 
better be burned. During occupancy as much sunlight as possible 
should be allowed to enter the room, and it should be kept at an even 
temperature of 70° F., and be well ventilated; an open fireplace is of 
great advantage. 

While the fever is high milk is the best food, and after the tempera- 
ture declines a bland soft diet may be allowed. The child should 
drink plenty of water, and when the fever runs high (103° F. and 
above) tepid or cool spongings will afford relief. 

The skin should be anointed with a boric acid ointment or with 
cocoa butter to lessen the tension; if the itching is severe, with a 
1 per cent, phenol ointment. Cold cream, sweet oil, 5 per cent. 
ichthyol ointment, and oil of eucalyptus have all been used to relieve 
the skin irritation. The scales should be removed by daily baths of 
tepid water and green soap. 

The throat symptoms require treatment according to their severity; 
when mild no local applications are necessary, although saline or 
boric acid washes and sprays may be used as prophylactic measures. 
If an exudate is present in the throat, 25 or 50 per cent, hydrogen 
peroxide solution, or 1 to 5(100 bichloride, or 1 to 60 carbolic acid 
solution may be used locally as a spray. If the nose is involved, it 
should be gently irrigated with a normal saline solution. 

Cold applications externally, such as ice-bags to the throat, afford 
great relief and are very soothing. Careful attention to the throat 
tends to prevent otitis; but, if it occurs, the pain can often be relieved 
by gently syringing the ear with warm normal saline solution. The 
ears should be inspected daily, and if bulging of the tympanic mem- 
brane is observed myringotomy should be performed immediately. 

Nephritis is best guarded against by prolonged rest in bed and 
daily urinary examinations. The actual treatment of a complicating 
nephritis consists in restriction of the diet to milk and enforced rest 
in bed. In addition, the bowels should be kept opened freely, 1 or 
2 grains of calomel in divided doses being given at the onset', and 
followed by magnesium citrate, 2 to 6 drams, or magnesium 
sulphate, 1 to 2 drams. Alkaline diuretics are also indicated 
and 5 to 20 grains of potassium citrate mav be given everv three 
hours. 

Hot packs tend to make the skin more active, thus relieving the 
overburdened kidneys, and may prevent uremia and convulsions. 
If convulsions or uremic symptoms develop, the child should be put 



638 THE SPECIFIC INFECTIOUS DISEASES 

in a hot bath. If this has no effect, a hypodermic injection of -3V 
to 2V °f a grain of morphine, and ^-J-g- of atropine may be given. 
Lumbar puncture often gives excellent results in these cases. 

If a diphtheritic-looking exudate appears during the first week, 
it is usually a safe plan to administer 2000 to 5000 units of antitoxin, 
which can be repeated if it proves to be true diphtheria. In adynamic 
cases 20 to 40 drops of brandy may be given every three or four hours, 
and if the heart is weak 3V0T to tfo °f a grain of strychnine with 1 
to 3 drops of digitalis may be administered at like intervals. 

Malignant cases require continuous and powerful stimulation with 
whisky, 15 to 40 drops, caffeine, gr. J to \, and camphorated oil, 10 
to 15 drops hypodermically every two to four hours, according to 
indications. 

Cerebral irritation may call for the administration of either 
sodium bromide, 5 to 10 grains, Dover's powder, J to 1 grain, 
or codein sulphate, ■£$ to yV of a grain, three times a day. 
Vomiting and diarrhea, if troublesome, may be allayed by giving 
bismuth subnitrate, 10 to 20 grains, with paregoric, 5 to 15 drops, 
or Dover's powder, J to 1 grain, three times a day. For digestive 
disturbances in young children, small doses of calomel and bismuth 
are very efficacious. 

When the joints are involved they should be immobilized, methyl 
salicylate applied, and the joint then warmly wrapped in cotton- 
wool. Sodium salicylate, 5 to 10 grains, combined with twice 
this amount of sodium bicarbonate, should be given three or four 
times daily. If suppuration takes place in the joint, surgical inter- 
vention is necessary. 

The constitutional treatment of scarlet fever is largely symptomatic, 
since there are no known specific drugs. If the rash does not appear 
within the usual time, warm baths, a mustard bath, foot-baths, or 
a hot pack should be given, also hot drinks containing 10 grains of 
citrate of potassium, or 5 to 10 drops of sweet spirits of nitre. 
Constipation must be prevented. Antipyretics are contra-indicated; 
but ice-bags to the head are often a great comfort when the fever is 
high. 

Serum Therapy. — Good results have recently been reported from 
the use of antistreptococcic serum and from serum obtained from con- 
valescents. In those cases where the effect is favorable, one may 
note after an injection a drop in the temperature, a decrease in the 
pulse rate, and improvement in the force and rhythm of the heart. 
From 20 to 80 c.c. of antistreptococcic serum a day should be given 
in all malignant and complicated cases, as long as the dangerous 
symptoms continue. 

Convalescence. — During convalescence the child should be 011 a 
full, nourishing, and easily digested diet. A hot soapsuds bath should 
be given every second day, and this followed by an inunction of olive 
or sweet oil. After desquamation, if there is no nephritis, the child 
may play about out of doors; but should not be allowed to come in 



VARICELLA 639 

contact with other children for six weeks after the onset of the disease. 
If there is anemia, Ba sham's mixture, 10 to 20 drops, or tincture of 
ferric chloride, 2 to 5 drops, may be given three times a day 
after meals. The syrup of ferric iodide, 10 to 20 drops, and cod-liver 
oil, i to 1 dram, are also valuable tonics at this time. If possible, 
these children should be sent away to the shore or mountains to 
recuperate. 

VARICELLA (CHICKEN-POX). 

Varicella is an acute contagious disease, characterized by an erup- 
tion of vesicles on the skin together with mild constitutional symp- 
toms. In the vast majority of cases, one attack of chicken-pox 
protects the individual against the disease for life, and because nearly 
everyone contracts it during childhood it is rarely seen in adults. 
Varicella is quite separate and distinct from vaccinia or variola, and 
an attack of chicken-pox affords no protection against these diseases. 

Furthermore, inoculation with the virus of varicella, when suo 
ful, will produce varicella, and no other disease; likewise, variola 
inoculation will always produce smallpox. Vaccinia, varicella, and 
variola may occur successively in the same person within a relatively 
short space of time. 

Etiology. — Chicken-pox occurs both in endemic and epidemic 
form, though sporadic cases are frequently seen. Xo specific micro- 
organism has as yet been isolated. It is usually contracted by direct 
contact or conveyed by a third person, and may also be air-borne 
for a short distance. It is chiefly a disease of childhood, occurring 
in the vast majority of instances between the second and sixth years; 
but no age is absolutely exempt, as it is occasionally observed in 
very young infants as well as in adults. It is highly contagious, 
in this respect being somewhat like measles. Most cases are observed 
during the autumn months. The period of incubation is usually 
between two and three weeks, but it may be a little longer or a little 
shorter. 

Symptoms. — In the majority of cases there are no prodromes, 
but there may sometimes be a feeling of malaise during the later 
stages of the incubation period, while a day or so before the eruption 
appears there may be slight fever, headache, restlessness, and mus- 
cular pain. In exceptional cases a prodromal scarlatiniform rash 
has been seen upon the trunk. 

The onset occurs with fever, often with chills, and there may be 
angina, conjunctivitis, and even convulsions in severe cases. Occasion- 
ally there is vomiting, with pains in the back and legs. Often the 
first symptom noted is the eruption, which usually appears first 
either on the face or the trunk, but may occur without any character- 
istic grouping upon any part of the body. In some instances exan- 
themata may be seen upon the mucous membranes of the mouth, 
palate, tongue, and throat, and exceptionally on the nasal and vulvar 
mucous membranes. 



640 THE SPECIFIC INFECTIOUS DISEASES 

As a rule the eruption is scant upon the extremities, the hands and 
feet being rarely affected. It appears in the form of small, red, 
elevated papules which, within a few hours, are transformed into 
vesicles containing a clear fluid. The papules generally appear in 
crops, soon followed by succeeding crops of new ones on the same or 
other parts of the body. The first crop of papules generally dries up 
before the appearance of the next one. In consequence, all stages of 
the eruption may be seen at one time upon the same part of the body, 
this being a diagnostic sign of great value. 

There is usually no umbilication of the vesicles. In the majority 
of cases they are flat, and vary in diameter from one-eighth to one- 
fourth of an inch. Seldom is the skin about the vesicle reddened or 
infiltrated. After the first or second day the fluid in the vesicles 
becomes purulent and, within twenty-four to forty-eight hours later, 
the vesicles show signs of drying up, this beginning in the centre, 
and producing a slight depression which somewhat resembles umbili- 
cation. 

Crusts form which, according to the degree of skin involvement, 
fall off any time between the seventh and twenty-first days. Only 
after the most severe cases, and when secondary infection has taken 
.place from scratching, are any marks left, pitting depending upon 
whether or not there has been involvement of the true skin. Even 
in such an event, the pits are few, and most apt to be on the face. 
A diagnostic point of value is the fact that pocks are almost invariably 
seen on the scalp, which is rarely the case in smallpox. 

Frequently the rash becomes so modified that it assumes a peculiar 
appearance. Necrosis may occur about the pock, thus producing a 
condition known as varicella gangrenosa. This type of eruption is 
most commonly seen in institutions, where the children are apt to 
be puny and poorly nourished, and in these cases the disease may 
be fatal. It is believed to be due to a mixed infection. Or, the vesicles 
may become exceedingly large, and resemble bulla?, having all the 
appearance of pemphigus, this condition being known SLSvaricellabullosa. 

The constitutional symptoms in varicella are usually mild. The 
fever rises to 101° or 102° F. on the appearance of the eruption, and 
does not usually decline until the second or third day. It is slight 
except in severe cases, when it may rise to 104° or 105° F., and last 
four or five days. Usually it returns to normal as the rash gradually 
disappears, but may again rise with the appearance of a fresh crop 
of vesicles. Only when the skin lesions of varicella become second- 
arily infected does the temperature remain elevated for more than 
a few days. 

Hemorrhagic varicella is exceedingly rare; it is usually accompanied 
by bleeding from the mucous membranes. 

Diagnosis. — This is obvious if the case has been seen from the onset. 
The marked predominance of the rash on the trunk, the appearance 
of the eruption in crops of papules which change into vesicles and 
crusts, and the slight umbilication resulting from the drying of the 



VARICELLA 041 

vesicles, ought to render the diagnosis easy. In the absence of an 
epidemic of smallpox, the differentiation between smallpox and 
chicken-pox is not difficult; but when there is an outbreak of variola 
mild eases of smallpox may closely simulate varicella, and a severe 
attack of chicken-pox closely resemble variola. 

It should always be borne in mind that in varicella the temperature 
is lower and the duration of the fever shorter than in even very mild 
smallpox. The history of a recent successful vaccination renders 
the possibility of smallpox in that particular individual most unlikely. 
The superficial character of the pocks and their appearance in 
successive crops, the absence of infiltration and true umbilication, 
together with the mildness of the constitutional symptoms, are 
important factors in eliminating smallpox. 

Impetigo may be simulated by the dried crusts of chicken-pox; but 
in impetigo there are no constitutional symptoms, no lesions upon 
the mucous membranes, and the eruption persists for a longer period 
than do the skin manifestations of varicella. If the suspected case 
be chicken-pox, it can probably be traced to other cases, and it will 
run a shorter course than impetigo, the lesions disappearing without 
treatment. 

Complications. — Complications and sequelae are seldom observed, 
but occasionally pneumonia, pleurisy, bronchitis, laryngeal stenosis, 
otitis media, synovitis, or arthritis may be encountered. Polioen- 
cephalitis is a very rare complication which causes stupor or extreme 
restlessness and paresis of the extremities. A fatal termination is 
rare, even in these cases. 

Where there is suppuration about the pocks erysipelas may de- 
velop, and often proves fatal. Nephritis, though not a frequent 
complication, may occur either at the height of the disease or during 
convalescence. The urine passed by children who have chicken-pox 
often shows a trace of albumin. 

Other contagious diseases, particularly scarlet fever, may complicate 
varicella, especially in institutions; occasionally we may see simple 
or suppurative adenitis. 

Prognosis. — Simple uncomplicated cases almost invariably recover, 
for varicella is the mildest of all the acute contagious diseases with 
the possible exception of rubeola. Even in complicated cases death 
is uncommon, and a fatal outcome is never to be feared except when 
erysipelas, sepsis, or varicella gangrenosa occurs in weak, debilitated 
children. 

Treatment. — Children suffering from the disease should be isolated 
from other children for a period of at least two weeks, or until the 
crusts have completely disappeared, as it is while the vesicles are 
present that the contagion is at its height. If there is elevation of 
temperature, rest in bed should be enforced, and the diet restricted 
to liquids while the symptoms are acute. An initial purge of castor 
oil, 1 to 4 drams according to age, or 2 to 6 drams of citrate of 
magnesia, is also advisable. 
41 



642 THE SPECIFIC INFECTIOUS DISEASES 

In the majority of cases the constitutional symptoms are so mild 
as to require little or no treatment. The itching may be allayed by 
the application of a 2 to 3 per cent, solution of carbolic acid, 
or a saturated solution of sodium bicarbonate, or by the use of tincture 
of iodine or carbolized vaseline (2 to 3 per cent.). Warm baths 
will also relieve the itching, as will the application of the following 
ointment : 

1$ — Acidi salicylici, 

Thymolis aa gr.xx 

Ung. zinci oxidi gij — M. 

Sig. — Apply locally night and morning. 

Cases in which the rash is abundant, particularly upon the face, 
should be prevented from scratching the pustules by keeping the 
finger-nails closely trimmed and by applying splints to the elbows, 
if necessary, so that the affected parts cannot be reached; also by 
enclosing the hands in mittens tied securely at the wrists. 

If the vesicles are punctured as they become pustular, and a 
saturated solution of boric acid is applied, secondary infection and 
resultant pocking may be averted. A mild ointment, such as vaseline, 
may subsequently be applied to the crusts. 

MEASLES (MORBILLI— RUBEOLA). 

Measles is an acute contagious disease, occurring in epidemics, and 
characterized by an early eruption on the buccal mucous membrane 
and catarrrhal symptoms, later by a rash which covers the entire 
body, and by the development of bronchitis. 

Etiology. — The specific microorganism that causes measles is as 
yet unknown, but its viability outside the human body is not great. 
The disease can be reproduced in man by subcutaneous inoculation 
with the blood taken from a measles patient during the twenty-four 
hours before the eruption, and thirty hours after the first appear- 
ance of the eruption— in all fifty-four hours. 

According to Anderson and Goldberger, the virus can pass through 
a Berkefeld filter, and may resist desiccation for twenty-five and 
one-half hours. Its infectivity is destroyed by heating at 55 °C. for 
fifteen minutes. It resists freezing for twenty-five hours, and possibly 
retains some infectivity after keeping twenty-four hours at 15° C. A 
monkey which has acquired the disease by contact or inoculation 
remains immune. 

The virus exists in the blood and in the secretions of the nose, 
eyes, mouth, and bronchi of infected individuals, especially during 
the height of the disease, rapidly lessens as the rash fades, and 
disappears entirely with the disappearance of the rash. The disease 
is only slightly, if at all, contagious after the fading of the rash. It 
has been produced by inoculation with the blood, and the discharge 
from the eyes, nose, mouth, pharynx, bronchi, and vesicles of a patient 



MEASLES 643 

who has measles, but the contagion does not exist in the scales. No 
growth in any way connected etiologically with the disease can be 
obtained from the blood of a measles patient. 

Measles is easily spread from one child to another. A very short 
exposure is sufficient for contracting it, close contact not being neces- 
sary. Infants under six months are less susceptible than older chil- 
dren, w r hich is also true of rubella, and, in a less degree, of scarlet 
fever, but all other children, if exposed, usually contract it. The 
non-susceptibility of the newborn to measles is shown by the follow- 
ing case which came under my notice: 

Mrs. S. was seen on the morning of February 28, with coryza, a 
cough, a temperature of 102.4° F. The rash of measles covered her 
face and upper neck, and there were also a few isolated spots on her 
body. The following morning, after a normal labor at the end of 
the full period of uterogestation, a male infant, presenting absolutely 
nothing abnormal, was born. By this time the rash had spread over 
the entire body of the mother. The baby was free from rash, had a 
normal temperature, and presented nothing unusual. It was at no 
time isolated from its mother, was nursed regularly every two hours, 
and treated exactly as if it were not exposed to the contagion of 
measles. With the exception of a severe laryngitis, the mother made 
an uninterrupted recovery. When the infant was nine days old, 
another child of the family, a boy aged eighteen months, developed a 
typical attack of measles. Up to the age of six weeks, the baby 
had shown no symptoms of the affection. 

The disease may be acquired in irfcro, the mother having the 
disease, and the child show the typical signs of measles at birth or 
within a few days after birth. A. Bartsch reports a case where the 
infant was born on the day when the rash first appeared on the 
mother. When the baby was three days old, it presented the rash, 
temperature, and, indeed, a perfect clinical picture of measles. The 
child recovered without any complications. 

Another illustration of measles in early infancy is shown by the 
following case which occurred in my service in the Philadelphia 
Hospital : 

A baby was born December 4, 1912. The mother showed the rash 
of measles January 6, and it appeared on the baby on January 17. 
On January 20, the baby's temperature was normal, and the rash 
had faded. The rash in this case appeared forty-four days after birth. 

Epidemics are more severe in the winter and spring. The period 
of incubation is from nine to seventeen days, usually about fourteen 
days. The catarrhal symptoms generally appear eleven days, and the 
rash fourteen days after exposure to the disease. Measles occurs 
in all parts of the world. Boys and girls are equally susceptible. 

About 60 per cent, of all cases occur under five years of age, and 
almost 30 per cent, of the remaining cases in the next five years of 
life. If, however, measles is brought to a community which has never 
previously been infected, people of all ages are attacked by the disease. 



644 THE SPECIFIC INFECTIOUS DISEASES 

the old as well as the young. Many cases happen in young men and 
women who come to cities from isolated rural districts where they 
have never been exposed to the infection. Taking up their residence 
in a community where measles is always present they contract it. 
In the adult it is rare simply because almost everyone has the disease 
in childhood. It is, however, more common in young adult life than 
is scarlet fever. 

A third person may convey it, but only for a short time or distance, 
or it may be carried on the clothes, or on fomites which have been 
used by the patient. The disease is often contracted by large num- 
bers of children from a single case occurring in a school or at some 
entertainment given for children. It is contagious from the earliest 
catarrhal symptoms, and almost all who are exposed contract the 
disease. A second attack is rare, but may occur, and three attacks 
in one individual have been reported. 

Measles is endemic in all large cities, but most of the -cases occur 
in epidemics which recur at irregular intervals of two, three, or five 
years. As almost all children of school age are exposed and contract 
the disease, the epidemic disappears only when all of the susceptible 
children who have been exposed have contracted measles, and it 
reappears when there is a new enrolment of pupils. As school 
epidemics commonly spread the disease, a single case calls for prompt 
disinfection. It is especially contagious from the first symptom of 
the catarrhal stage, and, to a less degree, during the later or desqua- 
mating period. The infection does not cling or last after convalescence 
and at the end of three weeks the patient and the sick-room are free 
from it. 

Pathological Anatomy. — The main lesions are in the skin and mucous 
membranes. The skin shows a superficial inflammation, with conges- 
tion and swelling which involve the glandular structure and the 
papillae. There is invariably a catarrhal inflammation of the eyes, 
nose, mouth, pharynx, larynx, trachea, and larger bronchi. The 
cervical and bronchial glands are swollen, there is swelling of Peyer's 
patches, and, occasionally, degenerative change in the kidneys. The 
inflammation in the eyes, nose, larynx, trachea, and bronchi is a 
constant and integral part of the disease, and is not to be considered 
as a complication. 

The severity of this inflammation corresponds with the severity 
of the attack of measles. In severe cases in weak and delicate chil- 
dren, especially in hospitals, the inflammation may extend to the 
air vesicles, and produce bronchopneumonia, or the inflammation 
in the pharynx or larynx may assume a membranous form. The 
severe cases with marked involvement of the pharynx, larynx, or 
lungs are usually complicated with staphylococcic, streptococcic, 
or pneumococcic infection. 

An epidemic of measles in a hospital where a large number of found- 
lings are housed is often a most serious disease, owing to the frail 
and delicate condition of the young children, and their liability to 



MEASLES 



645 



infection with the streptococcus and pneumococcus. From a personal 
experience with a number of such epidemics in the Children's Depart- 
ment of the Philadelphia Hospital I am convinced that measles is 
a disease to be dreaded under such circumstances. General septicemia, 
due either to the pneumococcus or streptococcus, may also occur. 

Symptoms. — Prodromes, such as drowsiness, loss of appetite, rest- 
lessness, and disturbed sleep are common. 

Stage of Invasion. — The onset of the disease is gradual, with watery 
eyes, coryza, cough which is often croupy, and slowly rising fever, 
which usually reaches 104° F. by the fourth day, the highest tempera- 
ture ordinarily coinciding with the full development of the rash. 
The catarrhal inflammation of the mucous membranes also gradually 
increases, the eyes become more watery, photophobia appears, severe 
coryza develops with a croupy cough, hoarseness, pain on swallowing, 
and soreness of the throat due to congestion of the tonsils and pharynx. 

Koplik's spots — minute rose-colored spots with a central white 
speck— are seen on the mucous membranes of the cheeks or lips. 
The tongue is coated, headache and pain in the back are common, 
and nausea and vomiting may occur. The duration of this catarrhal 
stage is usually three or four days, although it may last only one or 
two days or may continue for seven days. Occasionally the onset 
is sudden with high fever, vomiting, even convulsions, and severe 
respiratory symptoms that suggest acute pneumonia. The symp- 
toms during these first three or four days are quite constant, varying 
less than is the case in scarlet fever, although occasionally they differ 
greatly from those described, especially in children under three years 
of age. Occasionally the disease sets in with a chili followed by high 
fever. 

The temperature in measles conforms usually to a definite type. 
The fever increases each day until the eruption is at its height, and 
falls quite rapidly after the eruption is fully established. 



d'JsWse 1 2 3 4 5 G 7 8 


m OMEMEMEMEMEMEMEME 


-104 


IZ~- ::m: 


",oi ^ 4 


1 . fp ^ , 


I 10 !] ~ " *x~~~ 


2 " / * \ 



Fig. 68. — Typical Fahrenheit temperature chart of measles in a child of six years; 
rash over entire body on evening of fourth day. 

Occasionally the fever is high at the onset— 103° F — falls to 100° 
F. on the second day, rises to 102° F. on the third day, and again 
reaches 104° F. with the appearance of the rash on the fourth day. 
A decline of the temperature on the second or third day may lead to 



THE SPECIFIC INFECTIOUS DISEASES 

an error in diagnosis unless one appreciates that the gradual increase 
in the severity of the catarrhal symptoms is of great significance. 
The symptoms and fever are most marked at the time the eruption 
appears. During this stage of invasion, the diagnosis can usually 
be verified by Koplik's spots. If the mucous membrane of the mouth 
is examined in a strong sunlight, a few or many stellate or round rose 
spots are seen, and in the centre of each is a bluish-white speck. They 
appear from one to three days before the rash on the skin, usually 
on the inner surface of the cheeks and lips, and are of great assistance 
in forming an early diagnosis; occasionally, they do not appear until 
the rash is present, and they cannot be detected by artificial light. 

Stage of Eruption. — The rash is first seen on the upper portion of 
the forehead, behind the ears, or on the neck, spreads over the face 
and scalp, and gradually extends over the trunk, arms, and legs. 
From the time of its first appearance until the entire body is covered 
is usually about thirty-six hours. When first seen it consists of small 
scattered red spots or macules, which rapidly increase in number, 
coalesce, and form slightly elevated papules. The rash is irregular in 
shape, often crescentic or oval; some blotches are large, others small, 
with more or less normal or slightly reddish skin intervening between 
the areas of rash. On the face the eruption is usually confluent, and 
the swollen face with discharging nose and eyes is very characteristic. 
The rash disappears on pressure, except in those cases where its color 
is a rather dark red, owing either to severe congestion of the vessels 
or to hemorrhage. This does not necessarily mean that the child is 
suffering from more than a moderately severe case. I have not 
infrequently seen this hemorrhagic rash in cases of measles that 
were of ordinary type and ran the usual course; sometimes, however, 
these cases were more than ordinarily severe. Cases with a rash 
that is more or less hemorrhagic must be carefully differentiated from 
the true hemorrhagic and the malignant forms of the disease. 

The rash remains at its height for twenty-four to thirty -six hours, 
and then begins to fade,- disappearing first from those portions where 
it appeared first, as the face and neck, and remaining latest on the lower 
extremities. It is often seen on the palms of the hands and soles of the 
feet. After the disappearance of the rash, a brownish staining of the 
skin persists for about a week. During this week, desquamation of the 
entire body occurs in the form of fine, branny scales, the scales being 
so minute that desquamation may, and often does, pass unnoticed. 
The more severe the rash, the more noticeable is the desquamation. 
During the spreading of the rash, the catarrhal symptoms, restless- 
ness, nervous symptoms, fever, and cough are most severe. The 
catarrhal symptoms gradually disappear as the rash fades, although, 
during this period as well as earlier in the disease, the cough is often 
persistent and annoying, disturbing the child's sleep and adding 
greatly to its discomfort. 

After the temperature declines to normal, the cough more or less 
rapidly lessens, loses its metallic or croupy character, and commonly 



MEASLES 



047 



disappears during the second week, although it may persist much 
longer. The appetite is poor, the tongue coated, and symptoms of 
gastro-intestinal ^indigestion are common. The child complains of 
itching and heat* in the skin, all the symptoms being most severe 
during the height of the rash. The rash does not always follow the 
typical course. It may be either distinctly papular or vesicular. The 
enanthem, or spots on the mucous membrane, may not appear; in 
rare cases the rash on the skin may be absent, although all the other 
symptoms appear. In mild cases the rash may be slight, of short 
duration, and followed by little or no desquamation. It is not uncom- 
mon for the rash to be darker than normal, of almost a purple color, 
and not to disappear on pressure. 

Leukocytosis is present in the latter part of the period of incubation, 
but during or after the appearance of the rash is present only if some 
complication develops. Conjunctivitis persists during the time of 
eruption, and the eyes are sensitive to light. Convalescence in uncom- 
plicated cases is rapid, and one week after the rash is fully developed 
the child is free from symptoms. 



°iVe°s\ 1 - 3 4 5 6 7 8 9 10 11 12 13 14 13 10 17 1* 


UJ CMEMEMEMEMEMEMEMEMEMEMEMEMEMEMEMEMEME 


§104 - -*- 
<103 -j\ A 


~m? ' ^ f\. I i *\ \ A ;\ 


I d-te- .^V^VlaAv. 


i$__ ._: ._„. ._^(_At— - 


7 i v T^ 


"■ \ 



Fig. 69. — Typical Fahrenheit temperature chart in measles complicated by broncho- 
pneumonia. Temperature normal on morning of eighteenth day; normal convales- 
cence. 



Hemorrhagic measles is marked by deep stupor, delirium, and con- 
vulsions. Hemorrhages in the skin and mucous membranes occur, 
the systemic symptoms are very severe, and a fatal issue is not 
uncommon. The so-called malignant cases are characterized by 
hyperpyrexia, marked prostration, severe nervous symptoms, decided 
toxemia, unusually severe inflammation of the affected mucous mem- 
branes, and either no rash or merely a few spots on the face. It is 
fatal on the second or third day, Hemorrhages may occur from the 
mucous membranes of the nose, mouth, stomach, or bowel, and blood 
may appear in the urine. A petechial rash may appear. Malignant 
measles may occur in epidemic form, or, occasionally, in an isolated 
case. 

Lack of hygiene, general weakness, and poor nutrition increase 
the liability to malignant measles, and the infection in these cases 
is of unusual virulence. The lung symptoms may be severe, the 
tongue is dry, sordes appear on the teeth, and* diarrhea is not 



648 THE SPECIFIC INFECTIOUS DISEASES 

uncommon. The eruption is dark blue, and does not disappear on 
pressure. 

Diagnosis. — Koplik's spots, which in the large majority of cases 
appear one, two, and, less often, four or five days, before the rash 
on the skin, are of great aid in forming an early as well as a differ- 
ential diagnosis. They can best be seen under strong sunlight, but 
often must be carefully searched for. These spots are slightly raised 
and firmly adherent, but can be removed by firm rubbing or by 
forceps. They disappear soon after the appearance of the rash. 
Leukopenia, coryza, and fever are present at this early period, and 
a diazo-urinary reaction when the rash appears on the skin. 

Rubella may closely resemble a very mild attack of measles, and 
a mild case of measles may be mistaken for rubella, but in rubella 
Koplik's spots do not appear, there are few prodromes, and none, 
or very mild catarrhal symptoms. The fever is usually 101° F. or 
lower, and is much shorter in duration. The rash is paler and smaller, 
spreads quickly, and does not persist as long as in measles. 

Cases of scarlet fever in which the skin eruption is atypical and 
resembles measles can also be differentiated, as Koplik's spots are 
not present. The rash of sepsis may closely resemble measles; but, 
as a rule, it is not as regularly distributed as in measles, being more 
apt to be on the extensor surface of the extremities, and the catarrhal 
symptoms of measles are absent. Serum rashes can be similarly 
differentiated. The rashes occasionally produced by quinine, antipyrine, 
the salicylates, and turpentine may more or less closely resemble the 
rash of measles, but their distribution is usually irregular, and neither 
fever nor catarrhal symptoms appear. 

Complications and Sequelae. — In private practice, in robust children, 
where the child is seen early, and receives skilful nursing and system- 
atic treatment, few complications occur. If, however, the child is 
delicate and under three years of age, complications are more common 
and more dangerous. I have had the opportunity of observing a 
number of epidemics of measles in the Children's Department of 
the Philadelphia Hospital, and in hospital practice, especially in 
delicate and poorly nourished children under three years of age, 
complications are common and often serious, and the mortality is 
high. Older children in hospitals do much better; complications are 
less common, less severe, and less dangerous. 

Respiratory System. — Catarrhal inflammation of the larynx is 
present in the majority of cases, severe laryngitis is not uncommon, 
and membranous laryngitis occasionally occurs, being seen more 
often in hospital than in private practice. It may be streptococcic 
or diphtheritic. The membrane may appear in the pharynx, may be 
limited to the larynx, or may be present in both pharynx and larynx. 
The tendency to membranous laryngitis is much greater in measles 
than in scarlet fever. Severe streptococcic infection of the throat 
may produce marked local and systemic symptoms, and may cause 
death by a widespread streptococcic infection ; moreover, as broncho- 



MEASLES 649 

pneumonia is often associated with a 'streptococcic infection, this 
dangerous complication may be added. Streptococcic laryngitis is 
usually associated with bronchopneumonia. 

If membranous inflammation of the larynx is suspected, cultures 
should be taken immediately, and diphtheria antitoxin at once given. 
The pseudomembrane that develops in the larynx previous to and 
during the stage of eruption is usually due to the streptococcus; 
the membrane that develops later than this is usually true diphtheria. 
Both are much more common in hospital than in private practice, 
and most frequent in children under four years of age. Measles 
following diphtheria is not especially dangerous; Hellstrom had 8 
deaths in 117 cases. Diphtheria following measles is much more 
serious, often being laryngeal in these cases, and early treatment with 
diphtheria antitoxin is necessary if life is to be saved. 

Bronchopneumonia is the most common and the most important 
complication of measles, being seen much more often and being more 
dangerous in hospital than in private practice. The younger the child 
the greater the danger, especially in children under four years of age. 
Most of the deaths from measles are due to bronchopneumonia; 
even when pneumonia is not the direct cause of death, more or less 
pneumonia is revealed at autopsy. This is, however, only what might 
be expected, since bronchitis is present in all cases of measles, and 
the tendency in children, especially if frail and delicate, to develop 
secondary bronchopneumonia is very common. 

Lobar pneumonia is occasionally a complication in older children, 
and usually ends in recovery. Pleurisy, either serous or purulent, 
may be associated with pneumonia, and increases the gravity of 
the prognosis. The association of measles and tuberculosis is not 
uncommon. Tuberculous meningitis and miliary tuberculosis fre- 
quently follow measles, but tuberculous bronchopneumonia is the 
most common tuberculous sequel. While it is, of course, possible 
that the tuberculous infection may occur subsequent to the develop- 
ment of the measles, it is nevertheless true that, in the large majority 
of cases, latent tuberculosis had previously existed, and the infection 
of measles, with the general catarrhal inflammation of the upper 
respiratory tract, had lighted up and made active this previously 
latent tuberculous process. Tuberculosis of the bones and of the 
cervical lymphatics are unusual sequelae 

Otitis is less apt to occur and is less severe than in scarlet fever; 
but is more common in children under four years of' age. Usually 
both ears are involved, but without serious damage. 

Stomatitis. — Catarrhal stomatitis is general y present, and herpetic 
and ulcerative stomatitis occasionally occur. Gangrenous stomatitis, 
or noma, is fortunately very rare, although it occurs more often with 
measles than with any other disease. It is a very dangerous compli- 
cation, but, if recognized early and energetically treated, is not neces- 
sarily fatal. It is rare outside of institutions and hospitals. Slight 
gangrene of the face, ears, genitals, and toes is not rare. 



650 



THE SPECIFIC INFECTIOUS DISEASES 



Eyes. — An ordinary catarrhal conjunctivitis is present in almost 
every case, and in institutions, or in weak and badly nourished chil- 
dren, this inflammation shows a tendency to continue and become 
chronic. Blepharitis and keratitis, acute or chronic, may occur. 
Choroiditis is unusual. 

Digestive System. — Loss of appetite is common. Diarrhea is of 
frequent occurrence, especially after the fading of the rash, and may 
be mild or severe, and in young children is especially common in hot 
weather. Its prompt treatment is important, as, in the young and 
poorly nourished, it may prove a serious complication. 

Nephritis as a complication of measles is rare, although in severe 
cases a trace of albumin is usuallv found. 




Fig. 70. — Noma, or gangrenous stomatitis, following measles. 

Nervous symptoms are not common. Convulsions occasionally 
occur in very young children, and may be associated with affections 
of the ear, brain, or lung. 

Cervical adenitis is common, and may be subacute or chronic; 
suppuration rarely occurs. 

Tuberculous adenitis is common, and myocarditis, endocarditis or 
pericarditis may develop. The skin is, as a rule, not affected other 
than by the rash; but furunculosis, pemphigoid eruptions, impetigo, 
and erysipelas are, in rare cases, complications. Measles may be 
associated with diphtheria, pertussis, or scarlet fever, and the associa- 
tion of pertussis and measles is quite common, the one often following 
the other; if the two diseases coexist bronchopneumonia is a common 
complication. Hemorrhages from the mucous membranes are rare. 
Second attacks of measles are . extremely rare. A few cases have 
been reported of children who have undoubtedly had measles twice. 
Relapses are more common, the relapse being separated from the 
primary attack by an intervening period of a few days or weeks. 

Prognosis. — This depends upon the severity of the prevailing 
epidemic and the previous health of the child. Epidemics are usually 



1911. 


1912. 


1913. 


1914. 


1915 


72 


7 


49 


19 


45 


104 


19 


86 


32 


81 


96 


21 


53 


20 


38 


20 


2 


7 


4 


4 


4 





1 


1 





4 


1 








1 


305 


50 


199 


77 


169 



MEASLES 651 

more severe in cold than in warm weather. Age is an important 
factor; the younger the child the worse is the prognosis. Measles 
among the well-to-do and educated class is usually a mild infection, 
and in robust children is attended by but little danger. Among the 
poor and ignorant, especially if the child is frail and badly nourished, 
it is often a serious disease. If there is latent tuberculosis, it may 
be stirred into activity by an attack of measles, and become rapidly 
progressive. 

Number of Deaths in Philadelphia — Measles. 
Age period. 
Under 1 year 

1 to 2 years 

2 to 5 " 
5 to 10 " 

10 to 15 " 
15 to 20 " 
All ages 305 

If the temperature has a tendency to remain high after the rash 
begins to fade, some complication should be suspected, and this 
often proves to be bronchopneumonia. Severe diarrhea following 
measles, especially in the young and wasted infant, is dangerous, 
particularly in the hot summer months. Convulsions usually occur 
only in severe cases, and then add greatly to the gravity of the 
prognosis. 

Pseudomembrane in the pharynx or larynx demands the immediate 
use of diphtheria antitoxin, and I heartily approve of the practice, 
now so common in hospitals, and which I follow in my wards in the 
Jefferson Hospital, of giving each child on admission, an immunizing 
dose of diphtheria antitoxin. In institutions where a large number 
of young children are housed, and especially in foundling asylums, 
an outbreak of measles which attacks most of the children over six 
months of age is often associated with an epidemic of bronchopneu- 
monia,, and the mortality may be as high as 20 to 30 per cent. Eighty 
per cent, of all deaths in measles occur in children under five years 
of age. 

Prophylaxis. — The patient should be isolated in an upper room or, 
preferably, in two rooms with a bath-room. Free ventilation is of 
the utmost importance. Measles patients require as much fresh 
air as any others, and in my wards for measles at the Philadelphia 
Hospital, as well as in my private practice, an abundance of fresh, 
moving air is allowed. A sheet is hung at the door and kept wet 
with 5 per cent, carbolic solution; all articles, such as bed linen, 
dishes, etc., removed from the room should be immersed in 5 per 
cent, carbolic solution. 

It is important that all infants and young children be protected 
from the disease, also all delicate or badly nourished children, and 
those who have any tendency to respiratory diseases or to tuberculosis. 

In hospitals and institutions all measles patients should be imme- 
diately removed from the ward. The quarantine for measles should 



652 THE SPECIFIC INFECTIOUS DISEASES 

be twenty-one days; that is, the patient should be quarantined for 
seventeen days from the day the rash is fully developed. At the end 
of this period of quarantine, the room occupied by the patient should 
be thoroughly house-cleaned and disinfected, and the windows left 
open for three days to admit sunshine and moving fresh air. The 
room may then safely be occupied by other children. 

Any children in the family where there is a case of measles who 
have been exposed should not be allowed to return to school until 
after the period of quarantine has expired. In a hospital ward, the 
daily examination of all exposed children for Koplik's spots aids in 
the early recognition of such patients, and their temporary isolation. 

Treatment. — The eyes are cleansed frequently with a boric acid 
wash, and 1 per cent, unguentum hydrargyrum oxidum flavum 
applied to the lids. The nose, mouth, and throat should be kept 
clean by spraying with a mild alkaline solution. Liquor alkalinus 
antisepticus, diluted with four parts of water, is an agreeable and 
efficient preparation. This cleansing has a tendency to prevent the 
spreading to the ears and larynx of the catarrhal inflammation always 
present in the nose. 

The patient should be kept in bed until the rash has entirely 
disappeared and the temperature has been normal for two or three 
days. He should have only enough bedclothes to keep him comfort- 
able, and compresses, kept wet with cold water, should be applied 
to the eyes. The child's eyes should be shielded from direct sunlight, 
and the room should be kept rather dark. Dark glasses may be worn 
by older children. 

An abundance of fresh, cool, moving air is essential unless the 
child has severe laryngitis, when warm, moist air is to be preferred. 
The child is kept on liquid diet during the period of fever, and the 
bowels kept moved each day. A tepid bath once or twice a day, 
or sponging with a bicarbonate of soda solution, a teaspoonful in 
two quarts of warm water, will partially allay the burning and itching 
of the skin. 

The cough is usually the most annoying and distressing symptom, 
as, if persistent, it disturbs the sleep and aggravates the nervous 
symptoms. It is best controlled by heroin, gr. ^V to ^, or codein, 
gr. j-q, or Dover's powder, gr. j to ij, every two or three hours. 

Nervousness, restlessness, and headache are best relieved by gr. 
j to ij of antipyrin or phenacetin, repeated in three hours if necessary. 
For sleeplessness, trional, gr. v, once in 24 hours, is of service. The 
child should be given each day a warm cleansing bath followed by 
an alcohol rub. If the fever has been 103° to 104° F. for only 24 to 
48 hours at the time of the development of the rash, it requires no 
special treatment, but if of longer duration, and associated with 
restlessness and nervousness, it is best treated by an ice-cap, and a 
tepid bath, 95° to 85° or 80° F., with friction, the duration of the 
bath, five to twelve minutes, depending upon the resulting reduction 
of temperature. 



RUBELLA 653 

In severe cases, if the hands and feet arc cold, they should be kept 
warm with gloves, stockings, and hot-water bags. Cardiac depression 
should be combated with whisky, f'3ss to f'oj, every two to three hours; 
strychnine, gr. tvmT every three hours; camphorated oil, gtt. xv, 
hypodermically every four hours; tincture of digitalis, gtt. j to iij, 
every six hours, or caffein citrate, gr. j to ij every three hours. 

Children with pneumonia as a complication should he separated 
from other measles cases. In hospitals and institutions all measles 
cases should receive an immunizing dose of antitoxin, and in private 
practice any suspicious evidence of diphtheria should he similarly 
treated. Bronchopneumonia should he treated as directed under 
that disease. 

If, after the disappearance of the rash, cough persists, especially 
if associated with fever, bronchopneumonia is to he suspected, and 
the well-known tendency of such cases to become tuberculous should 
be borne in mind. Fresh air, rest, abundance of nourishing and easily 
digested food, the keeping of the digestion in good condition, and a 
suitable climate, with tonics — iron, arsenic and cod-liver oil — are 
all indicated. 

Laryngeal symptoms should be treated with a croup tent, creosote 
being added to the water in the croup kettle. If the symptoms indi- 
cate the development of laryngeal membrane, diphtheria antitoxin 
should be given, and a culture taken. If fever persists without 
apparent cause, suspect the ears, and if any local evidence of inflam- 
mation can be detected, puncture of the ear-drums should be per- 
formed. It does no harm, and the escape of the pus or sero-pus may 
at once relieve the symptoms. The child should lie on the affected 
side after the puncture. 

A child with bronchopneumonia following measles, especially in 
a hospital ward where there are other children between one and 
four years of age, should, if possible, be immediately isolated from 
all other measles cases, as the danger of an epidemic of broncho- 
pneumonia is well recognized; it has twice occurred in my wards 
in the Philadelphia Hospital. 

RUBELLA (ROTHELN— GERMAN MEASLES). 

Rubella is a contagious disease occurring in epidemic form, char- 
acterized by mild catarrhal symptoms, a diffuse eruption of rose- 
colored macules which may resemble either measles or scarlet fever, 
a slight fever lasting three or four days, and swelling of the superficial 
posterior cervical lymph glands. 

Etiology. — It is less contagious than measles, and is most common 
in the winter and spring. The virus is longer-lived outside the human 
body than is the virus of measles. It usually occurs in epidemics 
which recur at intervals of two to four years, and is almost, if not 
quite, as common as measles. It is generally transmitted by direct 
contact but can be carried for a short time or distance bv a third 



654 THE SPECIFIC INFECTIOUS DISEASES 

person or by fomites. It is contagious from the earliest period of 
the disease until the disappearance of the eruption. 

Infants less than six months old rarely contract rotheln, although 
it may occur before the age of six months, and may be present at 
birth or a few days after birth. Children between the ages of six and 
twelve months are more susceptible and after the age of one year 
all those exposed to rubella are likely to contract it. Like measles, 
all ages are susceptible. The specific virus of rubella is as yet 
unknown, but an attack of rubella does not protect from either 
measles or scarlet fever. 

Symptoms. — The period of incubation varies from 5 to 21 days, 
although it is usually 10 to 20 days. Second attacks and relapses 
are rare. 

Stage of Invasion. — The symptoms are generally very trivial and 
transient, and may be easily overlooked. There is slight coryza, 
pharyngitis, and larvngitis, associated with general malaise. The 
fever is moderate, 100° F. (37.8° C.) to 102° F. (38.9° C). In the 
rather rare cases where the children are quite ill, the symptoms may 
be severe; headache, chills, a sensation of weakness, pain in the back, 
catarrhal symptoms about as severe as in measles, and a tempera- 
ture of 100° to 103° F., with mild delirium, convulsions, and epistaxis; 
but these severe cases are not common. The prodromal stage lasts, 
ordinarily, only about 12 hours, although it may occasionally last 
three or four days. As a rule the longer the stage of invasion, the 
more severe is the attack. 

Stage of Eruption. — The eruption generally appears in 12 hours 
after the initial symptoms; very often the rash is the first sign of 
the disease, the prodromes having been so slight that they passed 
unnoticed. The rash usually appears first on the face, and spreads 
over the entire body in 24 hours. The eruption remains at its height 
on any one portion of the body usually for about 6 to 12 hours, 
and passes like a wave over the face, thorax, abdomen, and extrem- 
ities. It may be well-developed on the face, thorax, and abdomen 
before it has spread to the legs. It consists of small, round, or oval 
macules of a pale rose-color, slightly elevated and usually discrete, 
with areas of skin paler in color intervening. 

As the rash develops it often becomes confluent, and may simulate 
closely the eruption of measles. The lesions on the skin are usually 
smaller and more regular than in measles, and are not apt to be cres- 
cent ic. The rash is more apt to be confluent on the face than on any 
other portion; it is quite profuse over the scalp and is usually least 
upon the legs. It fades first where it appears first, lasts from two to 
three days, is followed by a fine, bran-like desquamation, and later 
by an indistinct pigmentation which lasts for only a few days. In 
other cases the rash is very fine, pin-head in size, and spreads over 
portions of the body like a blush, resembling closely the rash of scarlet 
fever. 

In rubella jind measles the rash appears on the lips; in scarlet fever, 



RUBELLA 655 

the margin of skin around the mouth is usually free from rash. There 
is slight itching and the posterior cervical lymph glands are enlarged; 
usually, however, the lymphatic swelling persists for only a few days. 
The spleen is usually moderately enlarged; slight cough, a mild phar- 
yngitis, slight laryngitis, coated tongue, and occasionally nausea 
and vomiting are present. 

The severity of the symptoms varies greatly in different epidemics 
and, while the fever and constitutional symptoms are usually mild, 
epidemics have been reported where temperatures of 102° to 104° F. 
were common and associated with well-marked eruption and severe 
catarrhal and nervous symptoms. 

Forcheimer has described an enanthem which lasts for 24 hours 
or less. The enanthem is seen upon the uvula, soft palate, and, 
less often, on the hard palate. It consists of macules of pink rose- 
red color, the spots are the size of large pin-heads, and are only slightly 
elevated above the mucous membrane. The prodromal period of 
rubella is short, usually about 12 hours, and this enanthem which 
appears and fades away in the first 24 hours is present at or before 
the time the rash is appearing on the skin, so that at the most only a 
few hours intervene between the appearance of the enanthem and 
the exanthem. It is important to remember that the enanthem only 
persists for 12 to 24 hours. 

Diagnosis. — It is the variations in the rash that usually cause one 
to hesitate in making a diagnosis in the exanthemata, and in those 
cases where the rash is irregular and atypical, the diagnosis must 
often be made from studying the period of incubation, the prodromes, 
the initial and usual symptoms, the duration of the rash, the character 
of the desquamation, and the complications and sequelae. In a doubt- 
ful case it is best to quarantine and withhold the diagnosis for a few 
days. 

Rubella is to be diagnosed from measles and scarlet fever, and while 
this is usually an easy matter, in some cases it is difficult. If an 
epidemic of rubella exists, the diagnosis is simplified. Rubella shows 
a slight fever, an enlarged spleen, enlarged posterior cervical lym- 
phatics, an eruption that appears in the first 12 hours, and is of short 
duration, and a rose-pink enanthem, the size, of large pin-heads, on 
the uvula and soft palate, that appears either slightly before or at 
the time of the rash, and lasts for six to 12 or 24 hours. 

Measles has well-marked catarrhal symptoms, a higher fever, 
rash on the third and fourth day, an eruption that persists longer and 
is often crescentic, Koplik's spots, and more frequently complications, 
especially bronchopneumonia. .The difficulty arises in differentiating 
a mild case of measles, with very slight prodromes and moderate 
fever, mild catarrhal symptoms and slight rash, from a severe case 
of rubella. 

In such cases, if there is an epidemic of measles, if the period of 
incubation is definitely known to have been 11 days before the 
catarrhal symptoms, and 14 days before the rash appeared, these 



656 THE SPECIFIC INFECTIOUS DISEASES 

facts, and the knowledge that the catarrhal symptoms even in a 
mild attack of measles are usually much more severe than in a severe 
attack of rubella, point strongly to the diagnosis of measles and not 
rubella. 

If the eruption of rubella is of the scarlet-fever type, it may be 
impossible to make a diagnosis from the appearance of the rash. If, 
however, other features of the case are studied, a correct diagnosis 
is usually possible. Scarlet fever has a shorter period of incubation 
(from three to seven days),, the initial symptoms usually develop 
suddenly and are severe, with high fever, 104° F., and severe throat 
symptoms, and the enlarged cervical glands are at the angle of the 
jaw. There is pallor around the mouth, and a white line appears at 
the union of the finger-nail and pulp of the finger. The eruption 
persists for five or six days, and the desquamation is in flakes. The 
typical strawberry tongue is present, and ear and kidney complica- 
tions are common. 

Complications and Sequelae. — The disease is so mild that compli- 
cations are rare. Albuminuria, stomatitis, bronchitis, bronchopneu- 
monia, erysipelas, and severe sore throat are occasionally seen. Less 
often, pleurisy, enteritis, rheumatism, endocarditis, otitis and eye 
complications develop. 

Treatment. — The child should be isolated and quarantine should 
be maintained for two weeks. In hospitals or institutions, infants 
over six months of age, and young children should be especially pro- 
tected from the disease. The child should be kept in bed until the 
rash has entirely disappeared, should be given liquid nourishment, 
the bowels should be moved each day, and any symptoms which 
develop should receive appropriate treatment. 

DIPHTHERIA. 

Diphtheria is an acute infectious disease characterized by the 
production of a false membrane on the mucous surfaces of the throat 
or respiratory passages. The tonsils, soft palate, pillars of the fauces, 
the uvula, the pharynx, and the nares are the parts most frequently 
affected. The larynx is often involved, either primarily or by exten- 
sion, and the disease may be limited to this one part. 

In mild cases constitutional symptoms may be totally absent, but 
in severe forms there is marked prostration and cardiac depression. 
Frequently pneumonia and nephritis are complications, and paralysis, 
local or general, may follow. Diphtheria occurs endemically, epi- 
demically, and sporadically, and is, perhaps, less contagious than 
most of the other acute infections of childhood. 

Etiology. — The disease is the result of infection by a specific micro-, 
organism, and is at first local; later, as the result of absorption of 
toxins produced by the bacilli, it becomes systemic. 

The Bacillus diphtheria, also known as the Klebs-Loeffler bacillus, 
was first described by Klebs in 1883, and later isolated by Loeffler. 



DIPHTHERIA 657 

The organism is rod-shaped with rounded ends, and is either straight 
or slightly curved, varying in diameter from 0.5 to 0.8 micron, and in 
length from 2 to 3 microns. These bacilli vary greatly in form, and 
in the same specimen may be found either singly or in pairs. Some- 
times they form chains or parallel lines, and often an obtuse angle. 

The culture medium used influences greatlv the form and size, 
the bacilli appearing smallest and most regular on glycerin agar, 
and as segmented regular staining forms when grown upon Loe frier's 
blood serum. The bacillus stains well with ordinary aniline dyes 
and with the Gram stain. The stain most frequently used is Loeffler's 
alkaline solution of methylene blue, which makes the granules easily seen. 

In 1897, Xeisser advocated the following method of staining in 
order to differentiate the bacillus from other organisms which may 
closely simulate it. As described by Abbott it is as follows: The 
culture tested should be grown upon Loeffler's blood-serum mixture, 
solidified at 100° C. It should develop at a temperature not lower 
than 34° C. or higher than 36° C, and should not be younger than 
nine, or older than twenty-four hours. A cover-glass preparation 
is made from such a culture, and stained from one to three seconds 
in the following solution : 

Methylene blue (Grubler's) 1 gram 

Alcohol (96 per cent.) 20 c.c. 

When dissolved, mix with: 

Acetic acid 50 c.c. 

Distilled water 950 c.c. 

The preparation is thoroughly rinsed in water, and then stained from 
three to five seconds in vesuvin (Bismarck brown), 2 grams dissolved 
in a liter of distilled water, filtered, and allowed to cool. It is again 
rinsed in water, and is examined as a water mount, or dried and 
mounted in balsam. The bacilli, when stained in this manner, appear 
as faintly stained brown rods in which can be seen one to three brown 
granules. The granules are usually oval, occupy one or both poles of 
the cell, and bulge slightly beyond the contour of the bacillus in 
which they are found. In most instances the bacilli that do not 
stain in this manner are considered distinct from diphtheria organisms 
(Abbott). The bacillus is non-motile, aerobic, liquefying, and does 
not form spores. It is also a facultative, anaerobic organism (Stern- 
berg) . In the dry state it maintains its vitality for a long period of 
time. Abel found bacilli on children's toys, which had been kept in 
the dark, five months after exposure. 

The diphtheria bacillus may be found in the heart's blood, lungs, 
liver, spleen, kidneys, and lymph nodes, and is more easily demon- 
strated in these organs when the cases are uncomplicated. When 
diphtheria complicates scarlet fever, measles, and other diseases, 
there is usually a mixed infection, and staphylococci and streptococci 
are found, in addition to the Klebs-Loeffler bacillus. 
42 



658 THE SPECIFIC INFECTIOUS DISEASES 

Modes of Communication. — All cases of the disease have their origin 
in a previous case, either recognized or unrecognized. An individual 
may become infected by organisms in the air, or they may be taken 
into the mouth by kissing, or by the handling of toys, infected clothing, 
or other articles upon which they may have lodged. 

Occasionally diphtheria organisms are found in the throats of 
apparently healthy individuals without their having contracted the 
disease. Such persons are known as diphtheria carriers, and may 
be a source of infection to others. But there seems to be much evi- 
dence in favor of the theory that there are non-pathogenic as well as 
pathogenic diphtheria bacilli; unquestionably there is a great differ- 
ence in the virulence of the various types. 

Pharyngeal diphtheria is more contagious than other types because 
of the excessive amount of discharge laden with the organisms, which 
may readily be a means of infecting others. It is sometimes com- 
plicated by retropharyngeal abscess, the result of streptococcic 
infection of the lymph nodes in that region. 

A patient suffering with diphtheria may convey the disease to others 
for some time after the disappearance of the membrane. In some 
instances organisms have been found in the throat six to eight weeks 
after recovery. In large cities the presence or absence of bacilli in 
the throat after the termination of the disease is determined by means 
of a culture. Usually two negative cultures, taken on successive days, 
and at least twenty-four hours apart, are required before the quaran- 
tine is removed, provided fourteen days have elapsed from the date 
of onset. It is essentially a disease of children, and occurs only 
occasionally in adults. It is less common in the first year of infancy 
than in older children. 

Individuals are frequently infected directly through furniture, 
hangings, dishes, spoons, and other articles which have been in con- 
tact with a patient suffering from the disease. Milk may be a mode 
of transmitting diphtheria, and in rare instances water. The chief 
predisposing factors in children are enlarged tonsils and adenoid 
growths in the pharynx. The bacilli may lodge in the crypts of the 
tonsils and in the cavities of decayed teeth, and remain there for some 
time. Certain of the acute infectious diseases, particularly measles 
and scarlet fever, so affect the mucous membranes as- to make them 
extremely susceptible to diphtheria. It is most prevalent during the 
winter and autumn months. Predisposing factors are unhygienic 
surroundings, exposure to cold and dampness, faulty sanitation, 
overcrowding, neglect of the teeth and mouth, and chronic catarrhal 
conditions of the nose and throat. One attack in no way confers 
immunity against subsequent attacks of the disease. 

Children between the ages of two and six years are more susceptible 
than any others, susceptibility becoming less after ten years of age. 

Period of Incubation. — This period varies according to the virulence 
of the organism and the resistance of the individual. From two to 
five days usually elapse before the disease manifests itself. Con- 



DIPHTHERIA (559 

stitutional symptoms do not appear, as a rule, until after the character- 
istic exudate is seen. Nevertheless, in the majority of instances, the 
period of incubation is short. 

S3^mptoms. — Frequently there are slight prodromes, such as head- 
ache, anorexia, nausea, vomiting, and general malaise, prior to the 
appearance of characteristic symptoms. The lymphatic glands near 
the angle of the jaw may become tender, and there may be slight 
difficulty in swallowing. Sometimes convulsions may be the only 
symptom to usher in the disease. There is slight elevation of tempera- 
ture, frequently accompanied by a sense of chilliness. Gastro -intestinal 
disturbances are usually of no moment. In the laryngeal form the 
earliest symptom is huskiness of the voice, which is noticeable long 
before the appearance of the membrane, and is usually accompanied 
by a brassy cough together with dyspnea due to slight laryngeal 
spasms. 

The Throat. — In the throat, as a rule, is seen the first evidence of diph- 
theria, the tonsils being the favorite seat for lodgement and multiplica- 
tion of the organisms. Usually the tonsils are swollen, the fauces 
congested, and on the surface of the tonsils and in their crypts may be 
seen spots of exudate which rapidly spread and coalesce, often covering 
the entire tonsil. In the severe forms, especially when both tonsils are 
involved, the exudate has a tendency to spread to the fauces, covering 
both the anterior and posterior pillars, also the posterior wall of the 
pharynx, uvula, and soft palate. The nares and larynx often become 
involved. 

The exudate itself is either yellowish-white or dark gray, may be 
either thick or thin, and is usually extremely adherent, so much so 
that when removed it frequently leaves a bleeding surface. A distinct 
odor is observable after a few days, and often this alone makes one 
suspect the presence of the disease. 

Microscopically the membrane is found to consist of a network of 
fibrin, enclosing within its meshes epithelial and round cells which 
show evidences of degeneration; in the superficial layer are usually 
found a variety of other organisms as well as diphtheria bacilli. The 
epithelial cells of the affected mucous membranes show degeneration 
with fragmentation of the nuclei, and there is leukocytic infiltration of 
the mucosa which sometimes extends into the submucous and muscular 
layers. 

In some cases there is a resemblance to follicular tonsillitis, with 
practically no membrane formation, the fauces exhibiting merely an 
angina. The larynx is rarely involved in the mild and localized cases, 
and there may be few, if any, symptoms referable to the throat, so 
that, unless discovered on systematic examination of the throat, the 
diphtheritic aspects of these cases may pass unrecognized. 

In certain other types the diphtheritic lesions appear as strips and 
specks of exudate scattered over the tonsils, uvula, and posterior 
pharyngeal wall. These cases usually present mild constitutional 
symptoms, and are most common in older children. The onset is 



600 THE SPECIFIC INFECTIOUS DISEASES 

gradual, and is accompanied by a slight feeling of malaise and sore 
throat. The temperature rises to 101° or 102° F., and the lymph nodes 
behind the jaw become slightly enlarged. 

In some cases the children do not go to bed, so mild are the symp- 
toms. When these mild localized forms occur during infancy, gastro- 
intestinal manifestations often predominate, and there may be few 
symptoms referable to the throat, except slight swelling of the lymph 
nodes at the angle of the jaw. The fever ranges from 101° to 102° F., 
and the pulse and respiration are accelerated. In many infantile 
diphtherias, anorexia, and diarrhea with green, foul-smelling stools 
are the most marked symptoms. Owing to the prompt recognition of 
diphtheria and the liberal use of antitoxin, the majority of cases do 
not progress beyond this mild stage. 

Severe types do occur, however, and in these instances the membrane 
'not only forms extensively in the throat, but may also be in the nose, 
and occasionally in the larynx. The membrane changes from a 
grayish-white to a dirty greenish hue, and the child becomes extremely 
toxic. There is notable depression of the pulse, also extreme prostra- 
tion, difficulty in breathing, great swelling of the cervical glands, 
and of the lymph nodes at the angle of the jaws. The temperature 
is at no time very high, and varies between 101° and 102° F. throughout 
the greater part of the attack. 

The child is apathetic, with spells of extreme restlessness, has no 
appetite, suffers pain on swallowing, vomits whenever it attempts to 
eat, and frequently has diarrhea. Pain in the back and headache are 
usually quite severe. 

Albuminuria is always present in these cases, and not infrequently 
hyaline and granular casts may be found in the urine. In the severe 
types of diphtheria, a well-marked diffuse nephritis occasionally 
causes death. 

Nasal Diphtheria.— The nose is the common seat of involvement, 
after the fauces. Although the lesions here are frequently primary, 
the nose more often becomes involved by extension of the exudate 
from the throat. The mouth Is kept open, the child snores, has a 
foul breath, and is almost unable to swallow. As the membrane 
increases in thickness, the nasal cavities become occluded, and prevent 
the discharge from escaping; it now changes from a serous type, and 
becomes ichorous and blood-stained. This in turn prevents nasal 
breathing, and gives to the voice a nasal tone. On examination of the 
nose a whitish or greenish membrane is seen, and the anterior nares 
are eroded. After the detachment and expulsion of the membrane, 
which may sometimes be in the form of a distinct cast, there is a 
return of the nasal discharge, which may be copious. 

In considering the subject of nasal diphtheria it is important to 
remember that the Klebs-Loeffler bacillus may produce only the 
slightest irritation and discharge, no membrane being present; or 
it may produce the most intense inflammation with swelling and 
edema and membrane so extensive in amount as to more or less com- 



DIPHTHERIA 661 

pletely block the nares. The amount of contagion is usually in diiect 
proportion to the amount of discharge from the nose and nasopharynx. 
However, diphtheria may he, and not uncommonly is, spread from a 
case where little or no discharge is present, and yet Klebs-Loeffler 
bacilli in small or large numbers, and virulent, may be demonstrated 
as present in the nose. 

When one considers that these cases are apt to be overlooked; 
are not ill enough to wish to be confined to bed or within a certain 
room or rooms; have perhaps very slight local manifestations and 
no constitutional symptoms, it is not to be wondered at that par- 
ents fail to see the necessity for strict isolation, and that a more 
or less casual examination by the physician docs not disclose the 
real nature of the affection; and as membrane is more commonly 
limited to the posterior than to the anterior nares, its presence may be 
overlooked. 

Such cases are often the focus from which epidemics in a school 
or hospital ward may have their origin, and, while perhaps not danger- 
ous to the infected individual, arc a great menace to the community. 
It is impossible to say in any given case how long the contagion may 
exist, whether a, severe inflammation with membrane and profuse dis- 
charge is present, or a mild case with slight angina and no membrane; 
but it is absolutely necessary, for the safety of others, that all such 
cases should be isolated until no local manifestations remain, and all 
the diphtheria bacilli have disappeared. 

If, however, as will occasionally happen, the bacilli are found for 
more than a reasonable time, say two weeks after all local evidences 
of the disease, such as membrane, inflammation and discharge, have 
disappeared, then it is quite possible that these bacilli are not virulent 
and a guinea-pig should be inoculated, to test their virulence. It is 
also necessary to draw particular attention to the fact that it is often 
extremely difficult to distinguish between the true and pseudodiph- 
theritic bacillus, many bacteriologists claiming that it may be impos- 
sible to do so. If inoculations with guinea-pigs were more commonly 
carried on, and thus the virulent Klebs-Loeffler bacilli separated from 
those non-virulent, and the true bacilli from the pseudobacilli, there 
would be a. more earnest desire upon the part of physicians at large 
to cooperate with health boards in the reporting of cases, and many 
cases would be released from an unnecessary and uselessly prolonged 
quarantine. In considering the length of quarantine it is well to 
remember that diphtheria bacilli may often retain their virulence for 
at least four or five months outside the human body. 

The nose may be infected through the anterior nares. These are 
the cases where the infection is most likely to be limited to the nose. 
Both sides are more often involved than one side alone. The involve- 
ment of the sinuses and the antrum of Highmore may explain the 
persistence and the difficulty of removal of the bacilli in certain nasal 
cases. 

Only those cases are called nasal diphtheria that show an involve- 



662 THE SPECIFIC INFECTIOUS DISEASES 

ment of the nose alone. It does not include cases where pharyngeal, 
tonsillar or laryngeal diphtheria is present. 

Mild cases may be described as those with few or no constitutional 
symptoms, little or no membrane, very little nasal discharge. 

In moderate cases there are slight constitutional symptoms and 
persistent and often copious nasal discharge, which may be purulent 
and blood-streaked, excoriating the upper lip. It may persist for 
several weeks and yet the child be in apparently very good health. 
Membrane is usually present. 

In severe cases the nares are obstructed and the child breathes 
with difficulty through the nose, the mouth is kept open, respiration is 
labored, the tongue dry. Membrane can be easily seen, and small or 
profuse nasal hemorrhages may occur. The discharge often has a 
decided odor. The submaxillary and glands at the angle of the jaw 
are swollen and a distinct toxemia may exist. The child is asthenic, 
the pulse is rapid, weak and perhaps irregular; there is stupor and 
decided anemia. The blood shows a reduction in red cells and of 
hemoglobin, the reduction being in proportion to the severity of the 
case. There is usually a leukocytosis. 

The temperature is, as a rule, moderate — 100° to 101.5° F. Albu- 
min is usually present in the urine in severe cases. Hyaline and granular 
casts are present, but not in large numbers. Dropsy is uncommon. 
Nausea, vomiting and diarrhea are often present. A moderate degree 
of delirium is quite common. The membrane disintegrates slowly; 
it may be dislodged in a large cast or mass by a violent sneeze. 

The constitutional disturbances which accompany this form of 
diphtheria may be more severe than those in the tonsillar type. 
They are due to the ease with which toxins are absorbed by the injured 
capillary bloodvessels at the seat of membrane formation. Nose- 
bleed occurs even in the mildest types of the disease, and becomes 
in many instances extremely annoying. It is in this form of diphtheria 
that postdiphtheritic paralysis is most apt to follow. At times the 
disease assumes a chronic form, and has the appearance of chronic 
rhinitis. This is one of the modes in which infection is frequently 
conveyed to others, the individual affected being totally ignorant of 
the true nature of the discharge. 

The local and constitutional symptoms lessen rapidly with the 
disappearance of the membrane. The anemia and evidences of a 
weak heart are usually, however, slowly recovered from. 

The membrane which appears in the nose in most cases of scarlet 
fever and measles is not commonly diphtheritic, especially if it occurs 
early in the disease or during the height of the disease. Membrane 
occurring in the later stages of measles or scarlet fever is often diph- 
theria, and, if diphtheritic, the inflammation of the surrounding 
mucous membrane is, as a rule, not severe. 

As a diagnostic aid it is well to remember that the membrane in 
diphtheria may be found only in the nose; membrane not diphtheritic 
is rarely so limited. Albumin in the urine is suggestive of diphtheria, 



Diphtheria 663 

but if the case is a mild one, and no toxemia exists, albuminuria would, 
of course, not be expected to occur. Paralysis, especial 1}' regurgitation 
of liquids from the nose, would be in favor of diphtheria. 

A cover-glass smear will often enable one to quickly make a diagnosis, 
but a culture is more accurate, and as the local and constitutional 
symptoms are usually very mild, a culture is much to be preferred. 
Klebs-Loeffler bacilli may disappear early in the disease, and may 
not be found when the membrane has largely disappeared. If mem- 
brane is present all bacilli, which culturally and morphologically arc 
diphtheritic, should, in my opinion, be considered true diphtheria 
bacilli, unless proven pseudodiphtheritic by inoculation of a guinea-pig. 

Any child who is shown to have diphtheria bacilli in the nose, 
even if it presents no clinical evidences of the disease, is a possible 
source of danger, and the child should be isolated until the bacilli are 
proven to be non- virulent. Children exposed to diphtheria are 
known occasionally to have the bacilli in the nose, and animal inocula- 
tions prove that these bacilli may be virulent, and yet these children 
may not clinically develop diphtheria. Children in bad hygienic 
surroundings and in institutions, particularly, show this tendency to 
harbor the bacillus, and to have the disease develop into clinical 
diphtheria, also to spread it to other children, to a much more 
marked degree than where the conditions from a hygienic stand- 
point are first-class. 

In a doubtful case, especially if the child has been exposed to diph- 
theria, and a nasal discharge persists, a single negative culture is not 
positive proof that the case is not diphtheritic. 

An interesting question, and one which requires much careful 
future study, is the report of return cases. I believe that future 
investigation will conclusively prove that return cases occur in a 
greater proportion of instances than is now believed, and I do not 
approve of the doctrine that a child discharged from quarantine with 
diphtheria bacilli in the nose, who is clinically free from diphtheria, is, 
as is claimed by some careful observers, not able to transmit the 
disease. In fact, one hears continually from physicians abuse of 
health boards because two successive negative cultures must be 
obtained before the child is allowed out of quarantine. What is the 
risk incurred by children who come in contact with this child who has 
been clinically free from diphtheria for some days, and who, neverthe- 
less, has Klebs-Loeffler bacilli present in the nose ? Is one warranted 
in sending these cases out of private homes and hospitals without 
inoculating a guinea-pig to test the virulence of the bacilli? Return 
cases to hospitals do not show a very large percentage of infections 
from such patients. C. B. Ker, of Edinburgh, states that "Dr. 
Cameron found that 1.2 per cent, of the total diphtheria cases were, 
after their discharge from hospital, supposed to have infected persons 
with diphtheria." 

It is an interesting point, and one well worthy of discussion, as to 
how many of these return cases are real infections from the discharged 



664 THE SPECIFIC INFECTIOUS DISEASES 

case, and how many are cases of coincidence; by that, I mean, happened 
to contract diphtheria at this special time from a source other than the 
discharged patient, but contracted it just at the time when it would 
appear that infection had occurred from the discharged case. It not 
uncommonly happens that a second child from a family is admitted 
to the hospital a few days before the first child is returned home. 
If this second child had entered the hospital a few days after, instead 
of a few days before the first child was returned home, it would have 
been classed as a return case. However, there is no doubt in my 
mind but that all such cases with diphtheria bacilli in the nose, all 
clinical evidences of the disease having disappeared, are possible 
sources of danger. 

Every suspected case of nasal diphtheria should be quarantined 
and isolation continued until a bacteriological examination proves 
the case to be non-diphtheritic. Cultures should be taken from all 
exposed children; and those showing diphtheria bacilli should be 
isolated and the nose and throat appropriately treated. 

In nasal diphtheria the bacteria may show an unusual tendency 
to persist, and it is believed this may be due to the nasal sinuses and 
antrum being involved. The danger of harboring virulent bacilli in 
these cases of long standing is not very great; the bacilli are usually 
few in number, and experience proves that the risk of contagion 
is comparatively slight. It is unwise to admit into a hospital ward or 
institution any child who shows a membrane in the nose or has a nasal 
discharge, unless a bacteriological examination has shown the absence 
of diphtheria bacilli; and all children in hospitals or institutions should 
be carefully watched for the development of such symptoms. It has 
been the experience of almost all physicians with hospital experience 
to see epidemics of diphtheria in hospitals originate from such cases. 
The number of visiting days and the number of visitors to children's 
wards should be limited as far as possible, and no children should ever 
be admitted as visitors. All visitors, and, in fact, all persons entering 
a children's ward should wear a sterilized cap and gown. Such a 
rule has been inaugurated at the Jefferson Hospital, and, I believe, is 
of decided aid in preventing outbreaks of the disease. 

If the discharge is small in amount and there are no constitutional 
symptoms, it is unnecessary to irrigate the nose. In those cases 
where the discharge is abundant and the nasopharynx is more or less 
blocked with secretions, it is important to keep the nose and naso- 
pharynx cleansed with warm, mild antiseptic solutions. Normal salt 
solution, weak boric acid solution, 3 grains to the ounce, or borate 
and bicarbonate of soda, 5 grains of each to the ounce, may be used. 
All solutions should be used warm; no unnecessary force should be 
exerted, and the child should always be firmly wrapped from head to 
foot in a blanket. As the treatment is designed especially to wash 
out the nasopharynx, the fluid entering a nostril should escape from 
the opposite nostril and the mouth. A fountain syringe, in my 
opinion, is better than a piston syringe. Enough fluid should be used 






DIPHTHERIA 665 

to at least fairly well cleanse the nose and nasopharynx. It is rarely 
necessary to employ irrigation oftener than once in four hours. Nasal 
hemorrhage calls for great care in the use of the syringe, and unless 
the case urgently demands syringing, it is better to discontinue it, 
if hemorrhage has occurred. 

Antitoxin should certainly be given in every case of nasal diph- 
theria, and, of course, the earlier it is given, the better the result will 
be. In an infant it is dangerous to wait until a diagnosis can be 
confirmed by a bacteriological examination. In older children with 
only slight nasal discharge and no toxemia one may postpone giving 
antitoxin until the bacteriological examination confirms the diagnosis. 
To postpone the early use of antitoxin in a case of profuse nasal dis- 
charge, with membrane present, is, in my opinion, utterly inexcus- 
able. 

Laryngeal Diphtheria" or Membranous Croup. — This may either 
appear as true diphtheria or may be diphtheroid in character. In the 
true form there is a pseudomembranous exudation into the larynx 
and trachea which results in croup. The cause in this type is the same 
as in other types of true diphtheria, namely, the Klebs-Loeffler bacillus. 
In the diphtheroid type the pseudomembranc formed is the result of 
invasion by bacteria other than the diphtheria bacillus, chiefly 
streptococci, and occasionally staphylococci. 

It has become the custom to treat all cases of membranous croup 
as diphtheria, even though it is conceded that other organisms than 
diphtheria bacilli may be the factors in pseudomembranous produc- 
tions. In this type of the disease there is often little or no involvement 
of either the tonsils or the fauces, though the affection is believed in 
most instances to be the result of downward extension from these 
parts. Not infrequently cases are seen in which the disease is confined 
solely to the larynx. It is in this type that the exudate may extend 
into the trachea and bronchial tubes. 

In both the true and false types the symptoms closely resemble 
each other, beginning with hoarseness, slight at first, and with a 
cough, rough in character, to which the name of croup is given, and 
which lasts for a period of one or two days. Suddenly these symptoms 
become intensified and the breathing paroxysmal as a result of spasm 
of the glottis. Dyspnea develops, inspiration is accompanied by 
retraction of the lower intercostal spaces and the epigastrium, and 
expiration is difficult. 

The skin becomes livid, owing to imperfect oxygenation of the blood, 
restlessness is extreme, and an anxious expression due to fear of 
suffocation appears on the face, a condition which, once seen, is not 
soon forgotten. The fever is usually moderate throughout the course 
of the disease and attracts little or no attention. The pulse is rapid, 
and varies in frequency from 120 to 200. Usually in true membranous 
croup there is little, if any, amelioration of the symptoms during the 
daytime, such as often occurs in simple croup. Cough is paroxysmal 
in these cases, and membranous casts are frequently expelled. 



666 the specific infectious diseases 

In laryngeal diphtheria the early symptoms are vague, and are apt 
to be overlooked unless one is ever mindful of the possibility of diph- 
theritic involvement of the larynx. A little hoarseness, a croupy 
cough, and slight inspiratory dyspnea, as shown by recession of the 
suprasternal notch, supraclavicular spaces, and epigastrium are noted 
early in the case. These symptoms are progressive, and within six 
to twenty-four hours the disease is often fully developed. 

The voice becomes hoarse, husky, and finally lost. The dyspnea 
becomes more and more pronounced, the inspiratory stridor gradu- 
ally and continuously increases, the pulse becomes rapid, the face 
turns pale and is anxious, the alse of the nose dilate with each inspira- 
tion, the child is restless, perhaps pulls at its throat, and puts its 
fingers into its mouth. All the accessory muscles of respiration are 
brought into action. 

Gradually the child becomes weaker, drowsy, and heavy. Cyanosis 
of the lips and finger-nails develops; the skin is cold and covered with 
a clammy sweat. Since little air enters the lungs owing to the occlusion 
of the larynx with membrane, we hear very little vesicular murmur 
on auscultation. 

Early in the disease the temperature is not higher than 100° or 101° 
F.; but as symptoms of suffocation increase, the fever rises to 103° 
or 104° F. The child becomes more and more quiet, it ceases to 
struggle, and in infants death may ensue in thirty-six to sixty hours 
after the development of the disease. Older children usually live 
three to five or six days. 

Improvement in the symptoms usually occurs in those cases in 
which the false membrane is expelled in whole or in part from the 
larynx by a violent paroxysm of coughing or vomiting. Usually, 
however, the membrane quickly reforms, and the symptoms return. 

In membranous croup, the result of invasion by bacteria other 
than the diphtheria bacillus, the onset is not so sudden, but the fever 
is usually high, and frequently there is involvement of the glands of 
the neck. Often a false membrane forms on the tonsils or fauces. 
In this type of the disease a culture taken from the membrane is the 
only method of determining the infecting organism. 

The mild constitutional symptoms which accompany the laryngeal 
type may be accounted for by the fact that the lymphatic supply 
to the trachea and larynx is extremely small. The chief complication 
is bronchopneumonia, either the result of membrane extension into 
the bronchial tubes or inability to expel the mucopurulent material 
from the tubes. 

Other parts which may become involved are : 

1. Middle Ear. — By extension of the exudate through the Eustachian 
tube the middle ear may become involved, this resulting in acute otitis 
media. The tympanic membrane ruptures and suppuration takes 
place, the pus containing the bacillus of diphtheria together with other 
organisms. Although this is of rare occurrence, yet it is a possibility, 
and may produce temporary deafness. In some instances the deafness 



DIPHTHERIA 667 

may be permanent, this depending upon the extent to which the 
tympanic cavity is affected. 

2. The Eyes. — These may be involved, either primarily or secondarily. 
Conjunctival diphtheria is rare, but when it occurs the membrane 
spreads rapidly from one eyelid to the other, and there is an associated 
chemosis of the bulbar conjunctiva. There Is also a severe form of 
diphtheritic ophthalmia in which the cornea is perforated, and destruc- 
tion of the eye often follows. In the milder form there is simply a 
slight seropurulent discharge. 

3. The Skin. — The skin surrounding wounds and abrasions may 
become involved, and a membrane form over the wound or around it. 
This is most frequently seen about the mouth and lips as the result of 
extension in cases of pharyngeal diphtheria. When it occurs the 
diphtheria bacillus may be found in the exudate. 

Diphtheritic processes have also been observed in the trachea and 
bronchi, in the stomach, and on the genitalia. Wounds made by 
tracheotomy and circumcision are occasionally infected by the 
Klebs-Loeffler bacillus, and in the newborn the umbilicus may be 
involved. 

Septic Diphtheria. — During the course of diphtheria a septic condi- 
tion frequently arises which is the result of infection by other associated 
organisms; namely, streptococci and staphylococci. This type of 
infection is most apt to be seen in the nasal form of the disease with 
associated diphtheria of the fauces, the exudate showing every evidence 
of decomposition, and resulting in a fetid discharge from the mouth and 
nose. This process is often followed by ulceration of the nasal mucous 
membrane with resultant hemorrhage. The lymphatic glands of the 
neck rapidly become involved, are swollen and tender, and may 
eventually suppurate. In this type of diphtheria, in addition to high 
fever and a rapid pulse, there is frequently a rash over the skin, at 
first erythematous, and later becoming petechial. 

Other Symptoms of Diphtheria which Call for Special Attention. — 1. 
Fever. — There is almost invariably fever at the beginning of the attack. 
It varies in intensity according to the virulence of the infection, and 
usually ranges from 100° to 102° F. during the first forty-eight hours 
of the disease, falling to normal two or three days after the exudate 
makes its appearance. Should the temperature remain high through- 
out the course of the disease, it should suggest the existence of such 
complications as adenitis and suppuration. In laryngeal diphtheria 
the temperature is high in the terminal stage. 

2. Disturbances of the Circulation. — Very notable in diphtheria is 
the rapid pulse rate, which is out of proportion to the degree of tem- 
perature. The heart sounds become distant and weak. 

3. Nervous Disturbances. — In children convulsions may usher in 
the disease. They are most often seen in children who are delicate 
and of a nervous temperament. Delirium, though usually mild, 
may be seen in any of the forms of the disease. Occasionally there 
is perversion of the senses of taste and smell. 



668 THE SPECIFIC INFECTIOUS DISEASES 

Morbid Anatomy. — Lymphatic System. — The cervical lymphatics are 
most frequently affected. There is marked leukocytic infiltration 
together with minute hemorrhages, which ultimately result in resolution 
or suppuration. 

Spleen. — This organ becomes congested and swollen. The splenic 
tissue is soft, and degeneration of the cells is almost always present, 
together with enlargement of the follicles. Infracapsular hemorrhage 
is of common occurrence. 

Liver. — Degeneration and necrosis of the hepatic cells and leukocytic 
infiltration of these areas are frequently observed. 

Kidneys. — As a result of the toxins circulating in the blood, degen- 
eration of the epithelial lining of the uriniferous tubules occurs, and in 
the severe types of the disease a diffuse nephritis may be seen. 

Heart. — Myocarditis, particularly of the left ventricle, is apt to 
appear and is of varying intensity, according to the duration and 
severity of the infection. Cardiac thrombi account for a certain 
percentage of sudden deaths, and also result in the production of emboli 
in the lungs, viscera, and arteries of the extremities. 

Arteries. — Hyaline degeneration of the visceral arteries, infiltration 
of the adventitia, and degeneration of the endothelial layer, are the 
processes most likely to take place. 

Blood. — Reduction in both hemoglobin and the number of red cells 
occurs in practically all severe cases of the disease. There is usually 
leukocytosis, though this may. be wanting. 

Nervous System. — The brain may be the seat of both hemorrhages 
and embolism, and the spinal cord reveals evidences of hemorrhage. 
The cord itself is apt to show degeneration of the ganglion cells of the 
anterior horns of the anterior and posterior nerve roots, also at times 
of the columns of Goll and the pyramidal tracts. In cases of mild 
diphtheritic paralysis the lesions found are usually peripheral. Certain 
nerves, such as the spinal accessory, hypoglossal, pneumogastric, 
oculomotor, and cardiac nerves may show changes of degenerative 
type as the result of the toxin, and when so affected produce lesions 
common to the disease, namely, multiple neuritis. 

Lungs. — Bronchopneumonia is frequently found, and in a great 
number of instances is the responsible factor in causing death. It is 
usually the result of the aspiration of particles of membrane from 
the air passages, these containing streptococci and diphtheria organ- 
isms. Emphysema, when found, accompanies the laryngeal type, 
and, depending upon the duration of the illness, may be either vesicular 
or interstitial. 

Complications and Sequelae. — Hemorrhage may result from ulceration 
of either the nose or the throat, but is usually of minor importance. 

Kidneys. — Nephritis is one of the most frequent complications, and 
is seen earlier in this disease than in scarlet fever, although its course 
is somewhat similar. In practically every instance of the disease 
albuminuria appears from the second to the fourth day, though the 
amount of urine may not be altered; in fact, the quantity is often 



DIPHTHERIA 669 

increased. When nephritis does develop it is the result of injury 
to the parenchymatous tissue by the toxins during their elimination. 
This will show its presence by the appearance of casts, both epithelial 
and blood, and occasionally hyaline and granular. The amount of 
urine becomes scanty, and at times there is suppression. 

Lungs. — In laryngotracheal diphtheria the lungs frequently become 
the seat of bronchopneumonia, whereas in faucial diphtheria simple 
bronchitis is more apt to ensue. Lobar pneumonia may occur during 
convalescence, and the same may be said of pleurisy. 

Heart. — It has been stated by Jacobi that, no matter how mild the 
case may be, the heart's function becomes affected to a certain extent. 
Endocarditis and myocarditis are both the result of the action of the 
toxins circulating in the blood. Heart paralysis occurs with greatest 
frequency in the severe forms of diphtheria in which the child is 
apathetic, and shows evidences of extreme prostration. These 
evidences of heart failure, when seen, usually manifest themselves at 
the height of the disease, which is usually about the seventh day. This 
failure may result from paralysis of the cardiac nerves without any 
change in the heart muscle. The symptoms of heart failure are 
frequently preceded by vomiting. There then occur cyanosis and 
rapid pulse, which later becomes slow and dicrotic, and the muscular 
sounds are indistinct. The extremities become chilled as a result of 
the failing circulation, though the mind is often clear until death. 

All this may occur at any time during the stage of convalescence, 
often as late as the sixth or seventh week, and the child may have 
several attacks before one proves fatal. In other cases, sudden death 
may occur during convalescence from cardiac failure when there have 
been no preceding cardiac symptoms. Cardiac irregularity is common 
in children during convalescence, but does not necessarily prove fatal, 
and may disappear in the course of several weeks. Both measles 
and scarlet fever may complicate diphtheria, the reason being difficult 
to explain. When complicated by the former, the disease is apt to 
be more severe because of the changes in the mucous membranes 
produced by measles. 

Diphtheria may also be a serious complication of pertussis, frequently 
causing bronchopneumonia. When it occurs during the course of 
typhoid fever or in tuberculous children it usually proves fatal. 

Paralysis. — This is the most important of the sequelae, and occurs 
after the acute stage of the disease, most often during convalescence. 
The exact cause is not definitely known, but it is regarded as a toxic 
neuritis which affects the peripheral nerves. Most frequently it 
involves the palate, this resulting in nasal speech and the passage of 
food through the nose instead of into the stomach. There may also 
be anesthesia of the mucous membrane of the pharynx. The muscles 
of deglutition are the next in point of frequency to be involved, and 
then the eye muscles, chiefly those concerned in accommodation. At 
times strabismus and ptosis may be seen, more rarely facial paralysis. 
There may be paralysis of the lower extremities, from which complete 



670 THE SPECIFIC INFECTIOUS DISEASES 

recovery seldom occurs. Respiratory and cardiac paralysis may 
occur at any time during the stage of convalescence, and result in 
sudden stoppage of the heart's action and cessation of respiration. . 

There may be no preliminary symptoms, even in severe forms of 
cardiac paralysis. In other cases there may have been preceding 
cardiac irregularity, and often there is slight albuminuria. In many 
instances, the child is apparently in good health, when suddenly there 
is abdominal pain, dyspnea, cyanosis of the lips, slow, thready pulse 
with weak, scarcely audible, heart action, and coolness of the extrem- 
ities. Not infrequently a child will survive one or two of these attacks 
only to succumb finally. 

G astro-enteritis. — Disturbances of the gastro-intestinal tract are 
dangerous, and not uncommon, complications of diphtheria in infants. 
The diarrhea may become very severe, and in rare instances death has 
resulted from extension of the membrane into the esophagus, stomach, 
and intestine. 

Diagnosis. — The disease may be diagnosed both clinically and 
bacteriologically, though ofttimes the diphtheria organisms may be 
found in the throats of healthy individuals without any symptoms of 
the disease, consequently their mere presence does not constitute a 
diagnosis of diphtheria. Nevertheless, when they are present together 
with certain clinical evidences the diagnosis is complete. In a great 
number of instances the diagnosis is to be made from the clinical 
evidences alone, especially in cases where the exudate is rapidly spread- 
ing. In the milder atypical forms it frequently becomes necessary 
to determine by culture the presence or absence of diphtheria organisms 
in order to make a diagnosis and protect other members of the family. 

Clinically, the following factors ought to be of some help in making 
a diagnosis. The presence of a flocculent nasal discharge which later 
becomes blood-tinged, enlargement of the cervical lymphatic glands, 
the early appearance of croup, which becomes progressively worse, 
the presence of a grayish patch on the tonsils which rapidly spreads, 
at times over the soft palate and the uvula, are very significant of 
diphtheria. 

In instances where diphtheria is associated with scarlet fever or 
measles the variations may be so marked as to make diagnosis difficult. 
In cases of pseudodiphtheria the onset is, as a rule, rapid, the consti- 
tutional symptoms are marked, and there is a decided elevation in 
temperature. It rarely begins primarily in the larynx and only in 
extremely few instances is albuminuria an early symptom. The 
mucous membranes in pseudodiphtheria become exceedingly inflamed 
and the exudate present is easily removed by the use of a swab. 

A diagnosis of the unusual types of the disease may be made by a 
bacteriological examination. The following is the method used by the 
Philadelphia Board of Health: Physicians can obtain from the various 
police stations envelopes containing two tubes. One tube contains 
two small wires; at one end of each wire a small amount of cotton 
is attached. The other tube contains the necessary culture medium 



DIPHTHERIA 671 

which is inoculated by rubbing the swab over any exudate present, and 
then gently passing it over the surface of the culture medium. The 
cotton stopper is replaced in the culture tube, the swabs are placed 
in their original tube, and both tubes are returned to the police station. 
They are then sent to the Laboratory of the Bureau of Health, where the 
tube containing the. culture medium is incubated for a definite length 
of time, and then examined microscopically. The physician is notified 
by telephone whether or not any diphtheria organisms were found 
on the medium. Just prior to taking a culture no antiseptics should 
be used upon the throat, and great care should be exercised not to 
contaminate the culture medium with other organisms than those 
from the exudate. Sometimes we obtain a negative culture from a 
case of diphtheria which presents all the clinical evidences of the 
disease; again, we may obtain a positive culture from the throat of 
an individual who clinically has not the disease. In all cases, when 
clinical evidences are present, a positive culture constitutes a positive 
diagnosis. 

The conditions with which this disease is most apt to be confused 
are the various forms of diphtheroid faucitis and the faucitis of scarlet 
fever. 

Follicular Tonsillitis. — This disease is more often mistaken for 
diphtheria than any other throat affection. The exudate in this type 
does not show a tendency to spread and usually affects the tonsil crypts. 
It is easily detached, and when crushed gives off an extremely fetid 
odor. The constitutional symptoms are often intense. There are 
high fever, headache, chills, pains in the back and extremities. The 
throat is sore, swallowing becomes difficult, and there is tenderness 
about the neck at the angle of the jaw. Sometimes the disease may 
closely simulate mild diphtheria, and in such instances a bacteriological 
culture may be necessary to determine its true nature. 

Scarlet Fever. — The absence of eruption is a great aid in making 
the diagnosis, although the eruption in scarlet fever may be wanting 
or extremely mild, and an erythematous blush may accompany 
diphtheria. In such instances a history of exposure or the prevalence 
of an epidemic should form a clue. Of course, when desquama- 
tion occurs the question is readily settled, but often, as in follicular 
tonsillitis, a bacteriological culture is necessary. 

In scarlet fever, however, the redness in the throat is much more 
diffuse than in diphtheria, and when there is a membrane in the 
throat it appears to be embedded in the tonsil instead of upon it, as 
in diphtheria. Diphtheritic membrane, as a rule, forms late in 
scarlet fever, early membrane formation being due in most cases to 
streptococcus infection. 

Catarrhal Croup. — During the early stages this is frequently confused 
with membranous croup. In true membranous croup there is no 
amelioration of symptoms during the daytime, but they become pro- 
gressively worse, the hoarseness more intense, the breathing more 
difficult. Restlessness and cyanosis appear, and the typical tugging 



672 THE SPECIFIC INFECTIOUS DISEASES 

of the diaphragm is seen. In catarrhal croup an emetic frequently 
relieves all of the symptoms, whereas in true membranous croup 
this is not the case and there is usually no exudate in the fauces. 

Stomatitis.— In severe cases of this disease the minute ulcers may 
coalesce and form patches, which may cause confusion in diagnosis. 
The exudation in such instances is usually thin and never membranous, 
although here also it may be necessary to resort to bacteriological 
differentiation. 

Prognosis. — The prognosis should always be guarded, for a positive 
one is impossible. 

The mildness or severity of the attack does not necessarily have any 
influence on the prognosis because of the complications which may 
result and the rapidity with which the membrane frequently extends. 
At times what appears to be a very mild case suddenly becomes an 
exceedingly severe one; again, cases that are most severe in the begin- 
ning may suddenly change for the better, and make a rapid and 
uneventful recovery. 

Much depends on an early diagnosis, and the giving of antitoxin 
immediately upon seeing the case, if the local or constitutional symp- 
toms are severe. If the case is a mild one, we may wait for the result 
of the culture ; but it is worse than foolish to do so in severe cases. 

In uncomplicated cases in which antitoxin is given on the first day, 
the mortality is almost nil. If injected on the second day, the mor- 
tality is not more than 2 per cent.; if antitoxin is not given in these 
uncomplicated cases until the third day, it will be 6 per cent.; at the 
fourth day, 11 per cent.; and after this period much higher. 

There are times when the nature of the epidemic has a bearing on 
the prognosis. In some epidemics the cases are all exceedingly mild, 
whereas in others they are all of severe type, and the death-rate is 
consequently increased. The general health of the child has but 
little influence on the severity of the attack or the ultimate result, and 
the social status of an individual has little or no bearing upon the 
prognosis. Frequently children in families whose surroundings are 
poor show better recuperative powers than those who have all the 
necessities and comforts of life. Of course, where the surroundings 
are good, and everything desirable, the care of the patient is easily 
obtainable, the probability of recovery is naturally greater, and 
greater still are the chances of recovery from the sequelae of the disease. 

Number of Deaths in Philadelphia — Diphtheria. 
Age period. 
Under 1 year 

1 to 2 years 

2 to 5 " 
5 to 10 " 

10 to 15 " 
15 to 20 " 
All ages 481 388 361 323 188 

The mortality in children under five years of age is greater than 
at any other time of life. Infants and very young children frequently 



1911. 


1912. 


1913. 


1914. 


1915 


33 


26 


22 


19 


24 


93 


77 


87 


72 


70 


229 


163 


152 


141 


119 


100 


79 


79 


70 


68 


10 


12 


8 


9 


10 


2 


5 


1 


1 


4 



DIPHTHERIA 673 

succumb to laryngeal diphtheria, and at all ages diphtheria of the 
posterior nares and nasopharynx is the most rapidly fatal type, death 
being caused by toxemia. Diphtheria of the anterior nares is usually 
very mild; but mixed infection in diphtheria render the prognosis 
grave. 

Other conditions being equal, the extent of the membrane is an 
indication of the severity of the attack. Malignant and septic cases 
are often fatal. The presence or absence of complications also influ- 
ences the prognosis to a certain extent; thus, hemorrhage, acute 
nephritis, or the involvement of other organs is of serious import. 

Postdiphtheritic paralysis develops as frequently in strong children 
as in weaklings, and the outlook in* these cases depends upon the 
condition of the heart and respiratory muscles. Scrofulous children 
and those suffering from other constitutional dyscrasiae usually 
succumb. More male children are affected than females, but this is 
merely due to the fact that male children are more likely to be exposed 
because of the general tendency to allow them to play about the streets, 
whereas the girls are kept at home. Of great importance in prognosis 
is the question whether or not antitoxin is used early in the disease. 
In some cases the diagnosis is made so late that the use of antitoxin is 
of little benefit. Yet there may be exceptions to this, and children 
who, to -all appearances, were not likely to recover, have, especially 
after an intravenous injection of antitoxin, been brought back from 
what seemed certain death to complete recovery. 

Prophylaxis. — Every case of sore throat which looks at all suspicious 
should be promptly isolated from other members of the family until 
an accurate diagnosis can be reached, either by awaiting clinical 
developments or by a bacteriological culture. Other children in the 
family should be prevented from attending school or coming in contact 
with children outside the family until the diagnosis is settled, because 
of the fact that children in a family in which there is a case of diph- 
theria often have diphtheria organisms in their throats and, if allowed 
to be at large, may possibly convey the infection to others. Should 
any children in the family show the presence of diphtheria organisms 
in their throats, although not suffering with the disease clinically, they 
should be isolated, but not with the child who is ill. 

The sick-room should be, preferably, on the top floor. It should 
have the sunniest exposure, and all hangings, draperies, and unneces- 
sary furniture should be removed from it. A sheet should be hung 
at the door and kept saturated with a weak solution of carbolic acid, 
formalin, or a solution of chloride of lime. The surfaces of the rooms 
should be wiped off daily with a bichloride of mercury solution 1 to 
2000. Eating utensils and refuse from the room should be placed in 
a solution of carbolic acid, 1 to 30, and allowed to remain there for at 
least an hour before being taken out of the room. The nurse in 
attendance should remain in the room, and not come in contact with 
other members of the family. She should wear a long gown, that can 
be easily disinfected, to cover her ordinary dress, and a cap that will 
43 



674 THE SPECIFIC INFECTIOUS DISEASES 

cover her hair. These should be removed upon leaving the room, 
and left just outside where they can be readily put on before reentering. 
All towels, as well as handkerchiefs or other pieces of cloth used for 
cleansing the mouth and nose of the patient, should be immersed in a 
solution of chloride of lime and subsequently burned. 

In view of the fact that diphtheria organisms remain active in the 
throat of an individual who has suffered from the disease, often for 
weeks after apparent recovery, the child should be kept isolated until 
two negative bacteriological cultures are obtained on succeeding 
days, provided that a period of two weeks has elapsed from the onset 
of the illness. After two such cultures are obtained the patient should 
be removed to another room, and the sick-room thoroughly disinfected. 
This is best done by the use of formaldehyde gas. When the above 
principles of isolation and quarantine cannot be carried into effect it 
is wise to send the child, if possible, to a hospital for the treatment 
of contagious diseases. In this manner secondary cases are prevented 
and the health of the community at large is not jeopardized. 

All exposed children should not only be cultured, as previously 
stated, but should also receive an immunizing dose of antitoxin, 
provided they are not asthmatic. When a case of diphtheria develops 
in an institution, all children who have been in contact ought imme- 
diately to be cultured, immunized, and isolated, and should show a 
negative culture prior to being allowed to mingle with other children, 
even though they show no clinical evidences whatsoever of the disease. 
The dose for immunizing is from 100 to 1200 units, depending upon 
the age of the child. Individuals who nurse cases of diphtheria should 
receive a dose of at least 1200 units. 

In addition to immunization with antitoxin it is also advisable for all 
contacts to cleanse the nasopharynx and throat three times a day with 
a 1 to 5 solution of liquor alkalinus antisepticus or Dobell's solution. 
This precaution is particularly essential in those cases in which there 
are contra-indications to the administration of antitoxin. 

The Schick reaction, which has lately become popular, particularly 
in institutional work, is of some advantage in determining the sus- 
ceptibility of different children to the disease, thus indicating those 
to whom it is necessary to give antitoxin. The method of obtaining 
this reaction is as follows: 

Following the observations of von Behring, Schick determined that 
if the serum of an individual contained as much as y^- of a unit of 
antitoxin per cubic centimeter he possessed a sufficient degree of 
immunity. He further demonstrated that when an amount of diph- 
theria toxin equivalent to -^q of a minimal lethal dose for a guinea- 
pig weighing from 250 to 300 grams was intracutaneously injected, 
and was not followed by a reaction, the serum of the individual 
contained -£$■ or more of antitoxin per cubic centimeter. 

Should the amount of antitoxin present be less, there will be a local 
inflammatory reaction at the site of injection, due to the fact that 
the toxin injected is not neutralized, A negative reaction indicates 









DIPHTHERIA 675 

that the individual possesses sufficient immunity against the disease, 
whereas a positive reaction indicates that he is still susceptible and 
therefore should receive a sufficient amount of antitoxin to produce 
immunity. Before the introduction of the Schick reaction it had been 
our custom in the children's ward of Jefferson Hospital to test for 
anaphylaxis when immunizing by first giving a small dose of antitoxin 
and then a larger one if no untoward symptoms developed, but recently 
we have used the Schick reaction instead of the small dose of anti- 
toxin with, perhaps, more accurate results. 

Treatment. — The treatment of diphtheria has been properly classified 
into hygienic, local, constitutional, and with antitoxin. 

Hygienic Treatment. — The room occupied by the patient should 
be free from all carpets, hangings, and unnecessary furniture. It 
should be well ventilated, and the temperature kept at about 70° F. 
A room with an open fireplace and several windows is most desirable. 
The nurse should be the only one to occupy the room beside the patient. 
The physician in attendance should take every precaution to prevent 
the spread of the disease. While in contact he should wear a linen gown 
with a hood that completely covers his head. Upon leaving the room 
his face and hands should be thoroughly washed in a 1 to 3000 solution 
of corrosive sublimate. Absolute quarantine should be enforced, 
so as to prevent the possibility of infecting other members of the 
family. 

Local Treatment. — In view of the fact that the organisms of the 
disease are present in the exudate in the throat, and knowing that they 
continuously multiply and produce toxic materials which are respon- 
sible for most of the constitutional symptoms, it is the belief of some 
clinicians that local measures should be resorted to that will tend 
to prevent the multiplication of the bacteria. Numerous drugs have 
been used locally for some time past, and each physician has his 
favorite method and drugs for swabbing the throat. Today active 
cauterants are not often used, but reliance is placed upon antiseptics 
that will cause no damage to the tissues with which they come in 
contact, yet have destructive effect on the organisms present. Those 
most frequently used are potassium permanganate, 1 to 5000, car- 
bolic acid, 1 per cent., subsulphate of iron, potassium chlorate, and 
chloral hydrate or glycothymoline, 25 per cent, solution. 

As a rule these drugs are applied to the throat by means of a swab, 
brush, or spray. Another drug which may be used either in the form 
of a dry powder or a liquid is the salicylate of sodium. In young 
children and infants it is often extremely difficult to employ local 
treatment. In very young infants solutions can be dropped into the 
nostrils, and in this way they gain access to the fauces. 

The opinion regarding local measures has changed considerably 
within the past few years, and today the idea is not so much to prevent 
further multiplication of the organisms as to keep the nose, mouth, 
and pharynx clean. This is easily appreciated in view of the fact that 
by so doing the bacteria are to some extent prevented from gaining 



676 THE SPECIFIC INFECTIOUS DISEASES 

access to the larynx and bronchial tubes. Absorption of toxins is also 
delayed, and further toxemia prevented. Ordinary salt solution, 
Dobell's solution, or a saturated solution of boric acid will suffice. 
These can be applied either with an atomizer or a fountain syringe. 
The solution should be warm and in sufficient quantity thoroughly to 
irrigate the parts affected. 

For hemorrhage from the nose, if severe, solutions which are more 
or less astringent, such as alum, or a 1 to 3000 solution of adrenalin 
chloride, are required. The number of douchings necessary depends 
upon the amount of discharge. In mild cases three times a day is 
usually sufficient, whereas, in the severe types with profuse nasal dis- 
charge, it may be necessary to syringe the nose every third hour. For 
the relief of pain caused by the cervical adenitis, an ice-bag may be 
placed on the neck, or a 25 per cent, ichthyol ointment applied. 

Constitutional , Treatment. — The child should remain in bed through- 
out the attack. A purgative should be given at the beginning of the 
disease, preferably calomel, 1 to 3 grains, depending upon the age of 
the child. If the fever is high, nothing is more beneficial than tepid 
baths, that is, at 98° F. The use of such drugs as the coal-tar products 
should be discouraged, because of their depressing effect. 

The diet should be liquid, consisting chiefly of milk, alternating with 
broths. Feeding the child with diphtheria is an all-important, but 
often a difficult task, since the appetite may be completely lost. 
The nursling must be taken from the breast, and given breast milk 
from a bottle, unless there is diarrhea, when milk-feeding should be 
temporarily suspended until improvement is noted. The older child 
should be given broths, beef juice, fruit juices, and ice-cream in small 
quantities at frequent intervals. 

Everything possible should be done to build up the child's powers 
of resistance, and in some cases 1 to 2 drams of wine may be given 
four times daily with beneficial results. Water should be given 
freely. 

For many years past iron has been used internally during the course 
of the disease and has gained in favor because of its good effects, both 
generally and locally. It should be administered in fairly large doses 
and at frequent intervals, the amount, of course, depending upon the 
age of the child. Children one to three years of age may be given 
10 drops of the tincture every three hours, and older children 20 drops. 
An excellent method of administering it is in combination with gly- 
cerin. In instances where marked stimulation is necessary, the 
tendency today is to omit iron for a time, and rely upon stimulants. 

Bichloride of mercury is another drug which exerts a beneficial effect, 
and has been used for many years. It is frequently combined with the 
tincture of ferric chloride, and in this way the action of both drugs 
is obtained, and is unquestionably beneficial. The amount of bichlo- 
ride of mercury to be given needs some consideration, although there 
are few instances in which it has had any injurious effect. Jacobi 
states that a child one year old may be given § grain every twenty- 



DIPHTHERIA 077 

four hours in divided doses for many days in succession without any 
intestinal disturbance. 

Another drug used internally is calomel, in fractional doses, but 
because of its constant purgative effect it has lost favor, the weakness 
produced being greater than the benefit derived, save when given as 
a purgative at the onset of the disease. Chlorate of potash, because 
of its beneficial influence in stomatitis, has been extensively used in 
diphtheria; but because of the injury to the kidneys when given in 
doses large enough to have any good effect, its use has been more or 
less discontinued. 

Caffein citrate, 1 grain every three hours; strychnine, ytttt to ^^j 
of a grain hypodermically; digitalis, 1 to 5 minims, and alcohol are all 
useful in combating cardiac depression, especially the last, in view 
of the fact that there are few cases which do not need stimulation, in one 
way or another. It is most frequently used in the form of whisky 
or brandy. In numerous cases it is necessary to give it in compara- 
tively large doses, particularly in the more severe types of the disease, 
when as much as 1 dram hourly may be required, although in most 
instances half of this amount is sufficient. 

Serum Treatment. — To Behring belongs the credit of having de- 
veloped the use of antitoxin. In 1890 he announced that the serum 
of an animal which had been immunized against diphtheria was 
capable, when injected into other animals, of giving immunity to the 
disease, and also to effect a cure in those suffering from it. As to the 
exact manner in which antitoxin acts, no satisfactory explanation has 
as yet been given, but in all probability it exerts its good effect by 
neutralizing the toxins of the disease. It is probably a globulin, 
which combines with the globulin of the blood, and so prevents the 
growth of the organisms. 

The serum itself should be clear, though its color varies. It fre- 
quently contains a preservative such as carbolic acid, but should be 
kept in a cool place in an hermetically sealed bottle. As a rule each 
cubic centimeter is equivalent in strength to from 100 to 500 anti- 
toxin units. The animal commonly used is a horse which is positively 
free from glanders or tuberculosis. According to Park, the serum is 
produced by the Health Department of New York City in the follow- 
ing manner: 

A virulent culture of a Klebs-Loeffler bacillus at the end of a week's 
growth is rendered sterile by the addition of 10 per cent, of a 5 per cent, 
solution of carbolic acid. This is filtered through sterile filter paper, 
and after standing twenty-four hours is placed in bottles and kept in 
a cool place. Several horses are then injected with sufficient toxin to 
kill 10,000 guinea-pigs, each weighing 250 grams. Ten thousand units 
of antitoxin are injected with each injection of toxin. This produces 
fever, but after it has subsided, which is usually from three to five 
days, another and larger dose is injected. The doses of toxin are 
increased, and given at intervals from five to ten days, and at the 
end of two months' time anywhere from ten to twenty times the 



678 THE SPECIFIC INFECTIOUS DISEASES 

original amount is given. The horses are then bled, and the blood 
serum is tested for antitoxin. Those animals which yield less than 
200 units to each cubic centimeter are considered unfit for use. The 
remainder are subsequently given toxin in ascending doses and at the 
end of three months the serum from such animals should' contain from 
300 to 800 units of antitoxin to each cubic centimeter. The serum is 
obtained by inserting a cannula into the jugular vein of the horse, 
and the blood is received in Ehrlenmeyer flasks, allowed to clot, and 
the serum removed. The antitoxin unit is the amount of antitoxin 
sufficient to prevent the death of a guinea-pig weighing 250 grams from 
the effect of 100 fatal doses of toxin. 

Dosage. — Large doses of antitoxin are to be preferred under certain 
conditions to small ones, large amounts being required to neutralize 
the harmful "toxin" and the so-called "toxone." The latter is sup- 
posed to be responsible for the paralysis, and is only loosely taken 
up by antitoxin, and not in any great degree until all the "toxin" 
has been neutralized. This hypothesis seems to explain why antitoxin 
exerts a less favorable effect upon diphtheritic paralysis than one 
would, perhaps, expect. 

The severity of the attack, and to a less extent its duration, should 
be the most important guides in regulating the dosage. For many 
years small doses, namely, 1000 to 2000 units, were given, and these 
repeated at frequent intervals, if necessary . Studies made in recent years 
have demonstrated that it is more advantageous to give a larger dose 
early in the disease, such as 4000 to 5000 units, and that it is unneces- 
sary to give doses at such - frequent intervals, it being sufficient to 
repeat the dose after the lapse of twelve to eighteen hours. The total 
amount of antitoxin to be given during the course of the disease depends 
entirely upon the reaction obtained; in the majority of cases it is 
not often necessary to administer more than 15,000 units during the 
course of the illness, and in many cases a single injection of 5000 units 
is all that is required. 

The method of administration is as follows: A syringe is necessary 
which can easily be disinfected by boiling, and should be sufficiently 
large to hold 10 c.c. The site of injection is of little import, though 
the abdominal wall and the small of the back are favorable locations. 
The skin should be cleansed with soap and water, followed by alcohol, 
and all air should be expelled from the syringe. The serum is intro- 
duced slowly, and, after withdrawing the needle, a small wad of sterile 
cotton should be placed over the seat of puncture. Slight pain and 
general discomfort may follow its use. 

Limitations of Antitoxin. — When given early in the course of the 
disease the membrane ceases to spread, becomes soft, and loosens, often 
in the most striking manner. The nasal discharge diminishes, and 
within a few hours the temperature often subsides, the heart action 
improves, and the nervous symptoms lessen materially. When given 
late, antitoxin cannot be expected to undo the harm which has already 
been done, nor is it likely to have any influence on the other organisms 






DIPHTHERIA 079 

so frequently associated with the Klebs-Loeffler bacillus. Again, in 
some instances, even though antitoxin be given early, the poisoning 
seems to be so virulent that the antitoxin has little or no effect. In 
these cases, owing to the more rapid result produced, the intravenous 
or intramuscular injection of antitoxin is of advantage. 

Bronchopneumonia is, of course, commonly associated with the 
streptococcus and pneumococcus. But recent studies have proven 
that the diphtheria bacillus is more commonly than formerly supposed 
the cause of bronchopneumonia, and it may be the sole cause. Pneu- 
monia has been produced in rabbits by the Klebs-Loeffler bacilli 
inoculated into the larynx. Large doses of antitoxin have proven of 
marked benefit in some pneumonia patients, and it is well to give the 
child the benefit of the doubt in appropriate cases. 

The immunizing power which antitoxin has is shown by the fact 
that it will protect one from an attack of the disease, although the 
immunity so produced lasts but three or four weeks; this, however, 
can be prolonged by subsequent injections. The curative power of 
antitoxin is well attested by the lessened mortality since its use, 
the death-rate having dropped at least 50 per cent. The following 
table shows the average annual deaths from diphtheria and croup per 
10,000 of the population: 

Before antitoxin, Sinr-e antitoxin. 

1887 to 1893. 1896 to 1900. 

Per cent. Per cent. 

London 4.8 4.7 

Berlin 10.2 3.7 

Paris 6.5 1.3 

New York 14.5 6.3 

Chicago 13.1 5.0 

Denver 12.9 1.7 

Philadelphia (1890-1894) 11.9 9.6 

In Berlin and Paris, where the serum was employed freely, the 
beneficial results can be seen by a glance at the above table; whereas 
in some American cities, where the serum was not adopted by the 
local Bureaus of Health, the reduction in mortality was not so 
great. 

From the foregoing facts may be summarized the following: 

First. — In view of the lessened mortality and the marked influence 
upon the course of the disease, Behring's antitoxin is practically a 
specific remedy, if given early in the disease. 

Second. — In doubtful cases it should be given rather than await 
the findings of a bacteriological culture. This is especially recom- 
mended in younger children, in view of the fact that antitoxin is 
harmless when given to perfectly healthy persons. 

Third. — The amount of antitoxin given depends upon the severity 
of the illness and its duration, larger doses at long intervals being of 
more benefit than frequently repeated small doses. 

Fourth. — Diphtheria antitoxin cannot be expected' to have any 
beneficial influence upon conditions which are the effect of other 
organisms associated with the Klebs-Loeffler bacillus. 



680 THE SPECIFIC INFECTIOUS DISEASES 

Fifth. — All individuals, especially children, who have come in 
contact with a case of diphtheria, should be given an immunizing 
dose of serum. 

Sixth.— As some hours must elapse, probably twenty-four, at least, 
before we get the full effect of antitoxin injected under the skin, there- 
fore in toxic, laryngeal, and all other cases where a prompt reaction 
from the antitoxin is desired, it is advisable to inject it intravenously, 
since the benefits from intravenous injection are often noticeable within 
a few hours after its administration. If, owing to the small size of 
the vein, it is impossible to administer it intravenously, the antitoxin 
should then be injected into the muscle instead of under the skin. 

In the present state of our knowledge, should anaphylaxis influence 
in any degree the giving of diphtheria antitoxin? Elmer E. Heg, in 
an article on "Review of Theories of Anaphylaxis" in Northwest 
Medicine, writes: "As we all know, quite a number of sudden deaths 
have followed the use of diphtheria antitoxins, a number of them in 
cases of asthma, though some without history of asthma. In most, 
no history is given as to whether or not a previous injection of serum 
had ever been given. Goodall reports 90 cases in a children's hospital, 
in which, during a period of five years, there was a record of a second 
injection after the incubation period. Sixty gave evidences of reaction, 
mostly a rash of more than usual severity; 7 had severe symptoms; 
1 convulsions; 2 collapse, and 7 had chills and temperature as high 
as 105° F.; all recovered." 

Much literature has accumulated on the theories, phenomena, 
lesions and mode of death in anaphylaxis in the lower animals, but 
one has some difficulty in- finding much in literature regarding the 
serious results of anaphylaxis in man. 

C. B. Ker, of Edinburgh, advises caution in the administration of 
antitoxin in the treatment of relapses. He says: "Some caution 
should be exercised in the administration of antitoxin in the treat- 
ment of relapses. It is, on the whole, wiser to withhold serum if it 
has been given during the original attack. Owing, doubtless, to 
what is termed ' anaphylaxis' the sequela? of antitoxin are much more 
severe and much more frequent than we are accustomed to see in a 
primary case. Very profuse and irritating rashes, severe joint pains, 
and smart febrile reactions are all liable to occur early. A relapse 
is usually, though not always, comparatively mild, and, if there is not 
much evidence of toxemia and the larynx is not implicated, the serum 
can be dispensed with. I never hesitate, however, to give liberal doses 
if the symptoms are in the least urgent." 

Dr. E. H. Funk has given me some interesting data from the 
Municipal Hospital in Philadelphia. During a period of some months 
he had an opportunity of seeing all the children in the scarlet fever 
hospital, and during a similar period all the children in the diphtheria 
hospital. All' children in both of these hospitals are given one or 
more doses of antitoxin, and the curative doses are large ones. In 
the aggregate, a number of these cases have previously received either 






DIPHTHERIA 681 

immunizing or curative doses of antitoxin. Some children are known 
to have been given antitoxin on three different occasions, the intervals 
between the administrations being months or years. Rashes, joint 
pains and slight febrile disturbances were occasionally seen, and yet 
no symptoms of a serious nature were ever observed. 

A very unusual opportunity has been offered to study the results 
of repeated injections of antitoxin at the Widener Memorial School 
for Crippled Children, in Philadelphia. Dr. Albert D. Ferguson and 
Dr. William J. Merrill have kindly furnished me with the following 
data: From 60 to 90 children are in the home, the buildings being all 
modern and thoroughly up-to-date. Many of these children remain 
for years as inmates. In spite of all precautions an occasional case of 
diphtheria occurs. An immunizing dose of 1000 units is always given 
to all children who have been exposed, and large curative doses are 
administered. As a result of this policy, and the fact that children 
often remain for years in the home, it has happened that many children 
have received a number of doses of antitoxin at intervals of a few 
months. It is understating the case to say that many children have 
received diphtheria antitoxin on at least six different occasions. 
Rashes, joint pains and slight fever are occasionally seen, but no 
fatal case, or even alarming symptoms, have ever occurred. It seems 
only just to conclude from this that with our present knowledge one 
should disregard completely anaphylaxis in treating diphtheria cases, 
and use antitoxin, according to modern ideas, at the earliest possible 
moment, both for immunizing and curative effects. 

Future study is required to explain the symptoms in certain cases. 
Several cases have been reported where physicians, taking an immu- 
nizing dose of 1000 units, have had marked symptoms, such as 
unconsciousness and severe rash. 

To those who are influenced by anaphylaxis it may be pointed out 
that the concentrated serum is safer, inasmuch as a smaller measure 
by quantity is required. And as the intravenous injection gives a 
more marked and rapid result, the subcutaneous method is to be 
preferred, since the dangerous symptoms develop soon after the injec- 
tion is given, and it is reasonable to suppose that the slower absorption 
of the subcutaneous method is safer, therefore, than the intravenous. 

A conservative and safe method has been advocated, which should 
appeal to physicians and be applicable to a large number of cases; 
in fact, could be used in all patients, except where the symptoms 
were so urgent that a delay of a few hours might be dangerous to the 
life of the individual. This consists in giving a small initial dose of 
antitoxin, about the usual immunizing dose, in all cases where a 
previous injection of antitoxin has been administered. If no immediate 
reaction is observed, it is safe in a few hours to administer the remedy 
in appropriate curative doses. If the case shows an immediate reac- 
tion it is wiser not to administer a large dose, as it might not be 
safe. If the immediate reaction has occurred, the patient will have 
milder symptoms from the smaller dose, on the theory that the larger 



682 THE SPECIFIC INFECTIOUS DISEASES 

the dose, the more severe the immediate reaction. Recently, in the 
Jefferson Hospital, we have been using the Schick reaction with fairly 
satisfactory results. 

By its use one is able to separate the children that should receive 
diphtheria antitoxin from those to whom it should not be administered. 
In my judgment the Schick test is practicable only in those institutions 
that have adequate observation wards. Children who are admitted 
for adenoid and tonsil operations often leave the hospital in twenty- 
four hours after admission. In these cases the time in the hospital 
is often insufficient for the study of the Schick test. In the hospitals 
where children are admitted directly to*the wards, one or two days 
must elapse after the test is made before it is possible to know to whom 
antitoxin should be given. During this interval the child that requires 
antitoxin, either as a prophylactic measure to protect himself or as 
a protective measure for the other children in the ward, has received 
no treatment. 

Antitoxin Eruptions. — In certain instances a cutaneous eruption 
follows the use of antitoxin. This eruption may make its appearance 
at any time from the date the antitoxin is injected up to a period of 
a month after its use, but usually between the fifth and the twelfth 
days. Such rashes are generally urticarial in type, sometimes erythe- 
matous, and the latter often closely resemble the rash of scarlet fever. 

Other types of eruption which may occur are vesicular, bullous, and 
purpuric. Accompanying antitoxin rashes is an edema of the skin, 
most noticeable on the face. Though this rash may make its appear- 
ance on any surface of the body, it is generally first visible about the 
point of injection. Constitutional symptoms in the form of fever 
which lasts two or three days, headache, and .at times vomiting, 
usually accompany such rashes. Joint involvement, chiefly pain, at 
times swelling, is a notable feature in many instances. 

The diseases with which serum rashes are apt to be confounded are 
scarlet fever and measles, and sometimes it is almost impossible -to 
make an early diagnosis. As a rule the appearance of a rash after 
the use of the serum, especially its appearance first at the site of the 
injection, the sudden rise in temperature, together with certain joint 
symptoms, should be a guide to the differentiation. 

Operative Measures. — If, after the use of antitoxin and other 
measures, there is a marked increase in cyanosis and a gradual rise 
of temperature, intubation or tracheotomy should be performed. 
Which is indicated should be decided by the attending physician. In 
this country intubation seems to have the preference, though, there are 
instances in which tracheotomy is necessary, either because of the 
location of the membrane, a lack of skill in performing intubation, 
or some other concurrent condition. Too frequently is tracheotomy 
postponed, consequently the results are often not as good as they 
might be. 

Intubation. — We are indebted to Dr. Joseph O'Dwyer, of New York, 
for this operation. A set of instruments consists of seven* tubes, an 






DIPHTHERIA 683 

introducer, an obturator, a mouth gag, a gauge for measuring the size 
of the tubes, and an extractor. The tubes vary both in size and 
calibre so that they may be inserted into the larynx of a child of any 
age. They are made of hard rubber lined with metal. The head of 
the tube is oval, and on its left side is a small hole through which a 
string can be passed. This is to enable the operator to withdraw the 
tube should it be introduced into the esophagus instead of the larynx. 
Each tube contains an obturator which is fastened to the introducer 
before the tube is inserted. The extractor is so constructed that 
when its tip is introduced into the tube the action of a lever makes its 
jaws separate, and the tube is grasped and extracted. 

For the introduction of the tube the child should preferably be upon 
its back, with the hands fastened to the sides. A gag is then placed 
in its mouth, and the mouth opened widely. The tube is then attached 
to the introducer, and the index finger of the left hand is inserted 
into the pharynx until the epiglottis is located and pulled forward. 
Then, with the right hand, the operator passes the introducer with 
attached tube backward to the glottis, and on releasing the introducer 
by means of an attached thumb-piece, the tube immediately passes 
into the larynx. 

The obturator is then removed, while the tube is held in position 
by the tip of the finger. That the tube is in the proper position is 
soon indicated by the sudden relief of the dyspnea. In the meantime 
the attached string should be firmly held for fear the tube may have 
been inserted into the esophagus. Should this occur, the tube must 
immediately be pulled out. The string may be removed by cutting 
it, and pulling it through the hole in the head of the tube. 

Sometimes it is necessary to let the string remain attached because 
of the possibility of the tube becoming obstructed by membrane from 
below. In such cases the string may be securely fastened to the side 
of the face by a piece of adhesive plaster, or the loop may be carried 
over the ear. In addition to the sudden relief of dyspnea when the 
tube is properly inserted in the larynx, we usually note a severe 
metallic cough, and that the breath sounds assume a hissing character. 

Dangers of Inttibation. — In the hands of an unskilful operator 
much harm can be done, such as forcing the exudate downward into 
the trachea by the tube, thus causing instant death. False passages 
may be made by forcible introduction, or asphyxia may result from too 
frequent attempts. 

After-treatment. — Sometimes, after intubation, the tube is expelled, 
usually owing to the fact that it is of too small size. In all cases of 
dyspnea after intubation, a careful examination should be made to 
ascertain whether or not the tube is really in the larynx, for it is 
possible for it to be coughed up unnoticed, or it may be coughed up 
and swallowed by the child. 

The most perplexing question after intubation is in regard to the 
feeding. In some cases it is practically impossible for the patient to 
swallow liquids, whereas in others they are swallowed without any 



684 THE SPECIFIC INFECTIOUS DISEASES 

difficulty whatsoever. Coughing is brought on probably by some of 
the fluid getting into the trachea through the tube, and in consequence 
most of the liquid is expelled. This condition happily disappears 
after two or three days, but during the time it lasts it is often necessary 
to resort to semisolid food, such as scrambled eggs, junket, etc. 

Casselberry, of Chicago, advocates having the child lie with its 
head lower than its body while on its back, so that liquids which may 
gain access to the tube may have a better chance to run out. Should 
this fail, it may be necessary to resort either to gavage or feeding by 
the rectum. The former is accomplished by the introduction of a 
small soft-rubber catheter through the nose into the stomach. Infants 
who are breast-fed are usually able to swallow with little difficulty. A 
nipple shield should, however, always be used, or the child should be 
fed breast milk from a nursing bottle. 

To prevent the possible expulsion of the tube, children should not 
be held with the face downward nor should they be allowed to lie 
upon the face; in either of these positions the tube may be readily 
expelled with the slightest cough. 

The length of time necessary for the tube to remain in the larynx 
varies greatly in each case. Usually it should be allowed to remain 
for at least five days, though there are instances where it may be 
removed after two or three days. Sometimes the tube is coughed up 
with a mass of membrane, and in such instances it is well to withhold 
its reintroduction, as this .may be unnecessary, but should signs of 
dyspnea return, it must be reintroduced immediately. Should the 
tube become obstructed, it must be removed, and if coughed up or 
swallowed no alarm need be felt, as it is invariably passed from the bowel. 

Extubation or Removal of the Tube. — This procedure is considered 
more difficult than its introduction, and the technic is identically 
the same as that of intubation. The child is placed in the same posi- 
tion, the mouth is held open by the use of the gag, the index finger 
of the left hand is passed backward until the tip of the finger touches 
the head of the tube, the epiglottis is then tilted forward, the extractor 
is inserted with the right hand along the side of the finger, and the 
beak of the instrument is inserted into the opening of the tube. The 
extractor is then pressed down, which causes the two ends of the 
instrument to separate, and thus grasp the tube, which is then lifted 
out. Should there be any difficulty in removing the tube, it is wise 
not to continue the attempts too long, but to stop for awhile, and 
later try again. Should dyspnea occur, reintubation is imperative, 
consequently all cases of extubation should be carefully watched for 
the following hour. 

Morphine is usually given hypodermically after extraction, and 
an ice-bag placed over the larynx. Immediately after extubation all 
irritative influences should be guarded against, and the child should 
be kept in bed for at least two days. 

Prolonged Intubation. — There are cases in which it is necessary for 
the tube to remain in the larynx for a long period of time, the children 



DIPHTHERIA 685 

becoming markedly dyspneic soon after the tube is removed, which 
necessitates its immediate replacement. In such cases the tube may 
be expelled at frequent intervals, necessitating tracheotomy in order 
to prevent possible suffocation should they be where it is impossible 
immediately to replace the tube. 

Various changes in the larynx, such as thickening, cicatricial con- 
tractions, paralysis of the muscles, persistence of false membrane, etc., 
may necessitate prolonged intubation, though frequently the true 
cause is undeterminable. Inasmuch as tubes may produce ulceration 
of the larynx, they should be removed early when possible, but not 
until the condition of the patient warrants it. After the removal of 
a tube its reinsertion is sometimes impossible. In such instances, 
should alarming symptoms occur, tracheotomy is necessary. For 
the ulceration which frequently follows the use of the tube, O'Dwyer 
has advised the coating of tubes with astringents. 

For chronic inflammatory conditions of the mucous and submucous 
membranes of the larynx, Rogers has advised increasing the intra- 
laryngeal pressure by gradually inserting larger tubes until the largest 
sized tube has been worn for several weeks. This is then removed. 
In this way he has succeeded in dispensing with tubes which, in some 
cases, had been used for two or three years. In chronic stenosis of 
the larynx, O'Dwyer has advised opening the trachea, producing 
dilatation from below, and then inserting an intubation tube. 

Tracheotomy. — In recent years this method of relief from laryngeal 
obstruction has fallen into comparative disuse, largely owing to the 
beneficial results of diphtheria antitoxin, and to the practice of intu- 
bation which has replaced it. However, there are still occasions which 
call for this radical procedure, i. e., (1) When the membrane has become 
loosened in the larynx, and intubation may force it farther down. 
(2) When the membrane has been forced down into the larynx by 
unsuccessful attempts at intubation. (3) When membrane formation 
is too extensive to be relieved by intubation, and when cases have 
been intubated, and the membrane has formed below the tube. While 
the operation of intubation appears to be a simple one, it is often 
very difficult to perform, and a competent and experienced surgeon 
should always be secured to do it. 

The occurrence of laryngeal diphtheria can to some extent be 
prevented by an early diagnosis and promptitude in treatment, thus 
lessening the possibility of extension of the membrane into the larynx. 
When the larynx becomes involved the membrane slowly disinte- 
grates, becomes detached, and is expelled, consequently it is some- 
times advisable to give an emetic to promote its expulsion. Of course, 
this ought not be done unless the physician feels positive that the 
membrane is detached, and this is certain only when a peculiar flapping 
sound is heard in the larynx. 

Syrup of ipecac, in \- to 1-dram doses, is in all probability the most 
efficacious emetic to use in such circumstances, because it leaves no 
after-effects. Apomorphine, ^V grain, may also be used. 



686 THE SPECIFIC INFECTIOUS DISEASES 

Inhalations of steam were formerly quite generally used to detach 
the false membrane, but because of their depressing effect they are 
now seldom, if ever, resorted to. In addition to inhalations of medi- 
cated vapors, such as the compound tincture of benzoin, turpentine, 
etc., the internal use of mercury has gained much favor. It may be 
given in the form of calomel, in divided doses, extending over a period 
of from twelve to twenty-four hours. 

Before the introduction of antitoxin, calomel by fumigation was 
frequently employed in the treatment of laryngeal diphtheria, and 
there is much clinical evidence in favor of its use. Ten grains of 
calomel are dropped on a strip of tin, which is placed over a chamber. 
A lighted alcohol lamp or candle is placed in the chamber under the tin. 
The crib or bed is surrounded by sheets to form a tent, and the patient 
and nurse remain in the tent for ten to fifteen minutes, the nurse 
frequently taking long breaths of outside air from the opening in the 
tent. The patient apparently runs no risk of salivation, and the 
above precaution will protect the nurse. The fumigation may be 
repeated three or four times a day. 

PSEUDODIPHTHERIA. 

Synonyms: False Diphtheria — Scarlatinal Diphtheria — Croupous 
Tonsillitis — Streptococcus Diphtheria. 

Under this term may be grouped those inflammatory conditions 
of the mucous membrane of the throat, and upper air passages in 
which is produced a false membrane which is not associated with the 
Klebs-Loeffler bacillus. Because of the fact that the Streptococcus 
pyogenes is frequently found in such membranes, it is often called 
Streptococcus diphtherise. A diplococcus, called the Roux coccus, has 
also been isolated, and the Staphylococcus pyogenes may frequently 
be found in cases of pseudodiphtheria. Among the organisms which 
may cause membranous formations in the mouth and throat are the 
pneumococcus, the Bacillus coli, and even the gonococcus. The affec- 
tion is frequently confounded with diphtheria, and it has been esti- 
mated that from 25 to 35 per cent, of cases formerly thought to be 
diphtheria were nothing more than pseudodiphtheria. 

The diseases in which pseudomembranous inflammation is most apt 
to appear are scarlet fever, measles, whooping-cough, and typhoid fever. 
It may also develop as a primary affection. The general hygienic 
surroundings seem to have some bearing upon the development of the 
disease, in that it is more frequently seen in children living in insani- 
tary tenement houses, or among the inmates of institutions. The 
disease itself is but slightly contagious, which renders isolation and 
disinfection during its course unnecessary. 

Lesions. — The tonsils are, as a rule, the chief seat of membrane 
formation, save in secondary cases where the entire pharynx may 
be involved with extension to the mouth, nose, middle ear, and, in 
exceptional instances, to the larynx, trachea, and bronchial tubes. 



PSEUDODIPHTHERIA 687 

The membrane differs from that of diphtheria in that it is softer, 
and microseopically is found to contain a greater proportion of cells 
than the membrane of diphtheria. Nevertheless, it is practically 
impossible to distinguish the membranes of the two diseases micro- 
scopically, and in the majority of instances a bacteriological culture 
is necessary in order to make a diagnosis. The non-adherency of a 
pseudomembrane in primary cases is characteristic, whereas in second- 
ary cases the pseudomembrane may extend deeper, and the adjacent 
tissues become markedly congested and edematous, this affecting 
chiefly the tonsils, soft palate, and uvula. In some cases membranous 
casts of the larynx and trachea have been expelled. 

Symptoms. — The onset is sudden, accompanied by headache, 
vomiting, chills, loss of appetite, difficulty in swallowing, and sore 
throat. On inspection the tonsils are found to be reddened and 
swollen, and are soon after the seat of membranous patches. The 
membrane is usually yellow or gray, and loosely adherent, and, after 
three or four days' duration, disappears. The surrounding tissues 
are at the same time markedly inflamed, and the lymphatics behind the 
angle of the jaw are tender and swollen, and may suppurate. The 
constitutional symptoms usually subside by the third or fourth day. 
' Secondary cases of the disease in severe forms are usually seen in 
scarlet fever or measles. When accompanying scarlet fever, evidences 
of the disease may present themselves either at the beginning or 
from the third to the fifth day; whereas, when complicating measles, 
they are usually at their height when the eruption begins to disappear. 
Sometimes the larynx is involved, and then bronchopneumonia is apt 
to develop. 

In the secondary type of the affection the constitutional symptoms 
are usually quite severe. There is high fever, the pulse becomes rapid 
and feeble, prostration is great, and delirium or stupor may set in. 
Following such an attack there may be either suppuration or necrosis 
of the adjacent tissues. Fortunately, such occurrences are rare. 

Diagnosis. — The differentiation between pseudodiphtheria and true 
diphtheria can in most instances be made only by means of a bacteri- 
ological culture. When the disease is secondary to scarlet fever or 
measles, and appears during the height of the primary disease, the 
diagnosis is not so difficult, since true diphtheria more often develops 
after the primary fever has abated. If, in such cases, the first culture 
is negative, a second should always be made. 

Prognosis. — Primary instances of the disease usually terminate in 
recovery, the mortality being extremely low (3.5 per cent.) whereas, 
when secondary to one of the diseases mentioned, the mortality is 
usually from 15 to 20 per cent. 

Treatment. — All cases of membranous inflammation of the throat 
should be isolated and regarded with suspicion. In very young 
children antitoxin ought to be administered immediately, and a 
bacteriological culture then made to determine the organisms present. 
If the bacteriological findings prove the disease to be non-diphtheritic, 



688 THE SPECIFIC INFECTIOUS DISEASES 

the administration of antitoxin should be discontinued; but in no case 
should antitoxin be withheld until a positive diagnosis of diphtheria 
can be made. 

Locally the nose and throat should be thoroughly syringed with 
mild antiseptic solutions, such as liquor alkalinus antisepticus, 25 
per cent. In instances where the swelling and edema are marked, a 
spray of 1 to 10,000 adrenalin chloride solution often gives great 
relief. The drugs most frequently used as a direct application to the 
membrane itself are nitrate of silver in the form of a 10 to 15 per cent, 
solution, and a solution of bichloride of mercury, 1 to 1000. 

Should there be evidences of adenitis or cellulitis, the external appli- 
cation of an ice-bag affords great relief. Frequently a gargle con- 
taining chlorate of potash, 10 grains to 1 ounce, in combination with 
tincture of ferric chloride, J dram to 1 ounce, is of decided benefit in 
preventing further membrane formation. When laryngeal obstruc- 
tion occurs, intubation or tracheotomy may sometimes be necessary 
as in true diphtheria. 

PERTUSSIS (WHOOPING-COUGH). 

Whooping-cough is a contagious disease, characterized by catarrhal 
inflammation of the mucous membrane of the respiratory tract, 
together with irritability of the nervous system. It occurs in both 
epidemic and endemic forms. 

It is essentially a disease of child life, being seen most commonly 
in the first five years, and about 65 per cent, of all cases occurring 
during the first two years. It often attacks infants only a few weeks 
or months old, and in this respect differs from measles, scarlet fever, 
and diphtheria, which are rarely met with at this early age. 

It, however, occurs quite often in older children, is occasionally 
seen in adult life, and even in old age. It is very contagious, and almost 
all children, especially if they have a coryza or bronchitis, will, if 
exposed, contract the disease. 

In the majority of instances one attack confers immunity, second 
attacks being rare. Winter and spring are the usual seasons for the 
prevalence of epidemics, and such epidemics frequently either precede 
or follow epidemics of other contagious diseases, particularly measles. 

The disease is easily communicated from one person to another, 
most frequently by direct contact, though it is often contracted in the 
open air. The height of contagion appears to be in the early or catarrhal 
stage, although it is also contagious until the typical whoop disappears 
in the stage of decline. 

Children who are delicate or anemic are more susceptible than 
others. Bordet and Gengou have apparently isolated the trUe organism. 
They describe it as a small, ovoid bacillus, sometimes elongated, but 
more often so short as to resemble a micrococcus. The bacillus stains 
a pale blue with Kuhne's blue stain, and is negative to Gram's stain; 
it is believed by some authorities to belong to the influenza group. 






PERTUSSIS 689 

Pathology. — No constant pathological lesions are found, except a 
catarrhal inflammation of the respiratory tract, and sometimes a 
serous pleurisy. The paroxysms have been attributed to irritation of 
the upper air-passages in the region supplied by the superior laryngeal 
nerve, or to an irritation in the posterior part of the larynx between 
the arytenoid cartilages. Another view is that the paroxysms of cough- 
ing are due to a plug of mucus in the trachea. The most frequent 
complication is bronchopneumonia. In protracted cases the lungs are 
apt to show some degree of emphysema. In severe cases which prove 
fatal, hemorrhages may take place in the eye, ear, and brain. 

Histological studies have shown that in fatal cases of whooping-cough 
the action of the infecting bacilli is largely mechanical, since they arc 
found in great numbers in the epithelial lining of the respiratory tubes. 
There is also produced in pertussis a mild toxin which causes exudation 
of leukocytes into the lumen of the trachea and the bronchi from blood- 
vessels lying external to them. 

The changes which occur in the splenic lymph structures, in the 
lymph nodes of the gastro-intestinal tract, and elsewhere are also 
produced by this mild toxin, while in the blood there is lymphocytosis 
and the formation of an antibody which acts specifically against the 
Bordet-Gengou bacillus. 

Symptoms. — The period of incubation, though variable, is usually 
from seven to fourteen days. For convenience's sake, the symptoms 
are divided into three groups: the catarrhal, the spasmodic, and those 
in the stage of decline. 

Catarrhal Stage. — The catarrhal stage gives all the appearances of a 
simple cold; namely, fever, nasal discharge, and cough. These 
symptoms may be preceded by a period of anorexia, languor, and rest- 
lessness, especially at night. The cough also is most troublesome 
at night. The fever may be slight and remittent, and is present only 
in the first few days unless complications, such as severe bronchitis 
or bronchpneumonia, develop. Up to this time, no suspicion is aroused 
unless there is a history of direct contact. After five to ten days, 
however, it is noticed that the cough, instead of abating, is more 
frequent, and becomes spasmodic in character, occurring in paroxysms 
which gradually increase in severity and are especially troublesome 
at night, until the appearance of the typical whoop which marks the 
paroxysmal stage. Examination of the chest at this time shows a 
moderate degree of bronchitis. 

Spasmodic Stage. — In this stage the symptoms and physical signs 
of bronchitis are present, and the paroxysms of coughing gradually 
increase in number and severity. During the coughing the child's 
face becomes congested, and the eyes suffused. A typical seizure 
consists of a number (5 to 10 or 15) of short expiratory coughs without 
a single inspiration intervening. At the end of these expiratory coughs 
there is a long drawn out inspiration, and it is this inspiration which 
produces the whoop. This is followed by another series of expiratory 
coughs, then by another whoop, and this is repeated in a single 
44 



690 THE SPECIFIC INFECTIOUS DISEASES 

paroxysm two, three, or even six times, until the child coughs up a 
portion of thick, tenacious mucus, and the paroxysm temporarily 
ceases. 

Infants usually foretell the approach of a paroxysm by beginning 
to cry, and older children run to their parents, or support themselves 
against some object when the aura of vomiting or sneezing warns 
them of the coming attack. 

As the attacks become more severe, there may be hemorrhages 
into the skin, nose, throat, or conjunctivae. The face is puffy, especially 
about the eyelids, and there may be a great amount of venous stasis. 
Not infrequently well-marked bronchitis sets in at this stage of the 
disease. 

Vomiting often follows, and may be so persistent as to produce 
emaciation. Epistaxis sometimes occurs during the more severe 
attacks, although the amount of blood lost is usually slight. Some 
degree of prostration often follows the paroxysms, and convulsions 
occur in severe cases. 

The number of attacks during the day varies from five to fifty, 
according to the severity of the infection, and they may be provoked 
by laughing, crying, overloading the stomach, or any irritation of the 
nasopharynx and larynx. The paroxysms are always worse at night. 

In very young children the whoop is frequently absent, though the 
cough may be severe. The duration of the paroxysmal stage is usually 
between four and five weeks; in the milder cases it may last but a week, 
and in the more severe ones may continue for eight or ten weeks, 
and then recur upon the slightest provocation, such as a cold. As a 
rule, it reaches its height at the end of the second week, remains 
constant for two weeks, and then gradually subsides, the cough 
assuming the appearance of simple bronchitis. 

Stage of Decline. — This period is characterized by a decrease in the 
severity, and diminished frequency, of the attacks. The cough loses 
its paroxysmal form, gradually becomes catarrhal, and disappears in 
the course of about two weeks. 

Complications. — Hemorrhages frequently occur as a result of intense 
venous congestion, epistaxis being the most common, though rarely 
of any severity. Conjunctival hemorrhages, bleeding from the ears, 
petechia?, and, occasionally, hemoptysis may appear. Convulsions 
sometimes occur, probably as the result of engorgement of the cortex, 
although hemorrhagic or tuberculous meningitis may set in, and 
encephalitis has been reported. 

Hemiplegia, monoplegia, facial paralysis, aphasia, and disturbances 
of sight, hearing, and sensation may result from meningeal hemorrhages. 
Various psychoses, such as melancholia and hallucinations, have been 
known to complicate pertussis, and more severe forms of mental 
derangement, such as imbecility and idiocy, may supervene. 

In some instances emphysema may result from a severe paroxysm. 
Atelectasis, bronchiectasis, and edema of the glottis are among the 
rarer complications in the respiratory tract. Pulmonary affections 



PERTUSSIS 691 

are by far the most serious. Of these bronchopneumonia is responsible 
for the majority of deaths; it occurs more frequently during the winter 
and spring months. Miliary tuberculosis or phthisis may also be 
excited by an attack of pertussis. 

Other complications may occur, such as pleurisy, valvular heart 
disease, and nephritis, while gastro-enteritis is not an uncommon 
sequel in infants, and may terminate fatally. 

Diagnosis. — The characteristic whoop of the disease renders the 
diagnosis easy, although it must be borne in mind that there are 
cases in which this is absent. If the disease is prevalent, however, 
if there is a history of exposure, and the cough is uninfluenced by 
treatment, the disease can be no other than whooping-cough. Partic- 
ularly is this true if there is occasional vomiting after the paroxysms 
of coughing. 

The chest examination in the catarrhal stage reveals, as a rule, only 
a slight bronchitis to account for the severity of the cough, and this is 
quite characteristic of pertussis, although it is scarcely possible to 
diagnose the disease before the whoop is heard. A severe cough, 
worse at night, which brings on vomiting, and is unaccompanied by 
fever, is almost certainly pertussis. Leukocytosis may be of some 
value in doubtful cases. 

Recent experimental researches would seem to indicate that the 
diagnosis of pertussis may be made at any stage of the disease by 
means of the complement-fixation test. The procedure is the same 
as for other complement-fixation tests, pure cultures of the Bordet- 
Gengou bacillus being employed. 

Prognosis. — In early infancy, especially during the first year, whoop- 
ing-cough is an extremely fatal malady, owing to the serious com- 
plications so often encountered. The mortality has been estimated 
as at least 20 per cent, during the first year, and most of the deaths 
occur in bottle-fed babies who also suffer from gastro-enteritis, and 
finally succumb. After this age, the percentage of deaths decidedly 
decreases, and the prognosis depends upon the previous health of the 
child, and the presence or absence of complications or of constitutional 
diseases, such as tuberculosis or rachitis. 

Children affected during the summer months are more apt to escape 
that much dreaded complication — bronchopneumonia — than those 
attacked during the winter months. Fifty to 70 per cent, of deaths 
occurring during whooping-cough are due to bronchopneumonia. 
Following this are the various intestinal disorders, chief and most 
common of which is diarrhea. Other causes of death are convulsions, 
cerebral hemorrhage, asphyxia, and emphysema. 

According to Dr. Paul Luttinger, of the Bureau of Laboratories, 
New York City, the highest incidence and mortality — 56 per cent. — 
have been observed among females, the incidence and mortality in 
males being 44 per cent. This has been attributed to anatomical 
differences in the construction of the larynx, and is, perhaps, also due 
to a nervous system which is more susceptible in girls than in boys. 



692 THE SPECIFIC INFECTIOUS DISEASES 

The influence of sex is apparent at all ages, and it would appear from 
our present knowledge that it becomes more evident the older the 
girls are. 

It is difficult to state positively what the true case incidence mortality 
is. All cases of pertussis are not reported, especially the mild and 
atypical ones. The law, in Pennsylvania, placards the house, but 
excludes from school only the children who actually have the disease, 
allowing the other children to go to school if they are free from symp- 
toms. If this law were better understood by physicians and the laity, 
more cases would undoubtedly be reported. 

The true case mortality, when one includes the mild and atypical 
cases, is certaintly much less than statistics ordinarily indicate. 

Number of Deaths in Philadelphia — Whooping-cough. 



Age perk 


>d. 


1911. 


1912. 


1913. 


1914. 


1915 


rider one 


year . 


41 


53 


51 


135 


18 


1 to 2 


years 


37 


18 


25 


74 


17 


2 to 5 


« 


32 


22 


22 


45 


10 


5 to 10 


u ■ 


5 


6 


8 


10 


2 


10 to 15 


^i 











1 





15 to 20 


u 





1 












All ages 



116 100 106 266 ■ 67 



Treatment. — Children suffering from this malady should be promptly 
isolated from other children for a period of not less than six weeks, 
owing to the fact that the disease is invariably contracted by direct 
contact. Rest in bed is imperative in cases of unusual severity, 
together with an abundance of fresh air day and night. 

The treatment of pertussis is a subject which has always absorbed 
a large degree of medical attention, and the mere enumeration of 
all the drugs, inhalations, and cures which have from time to time 
been brought forward would consume far more space than is here 
possible. I will not, therefore, attempt to mention the drugs and plans 
of treatment that might properly be considered in a historical sketch 
of this much-to-be-dreaded disease, but will call attention to only a 
few of the drugs and methods of treatment that have in my judgment 
stood the test of long experience, such as fresh air, careful attention 
to feeding and digestion, local applications to the nasopharynx, 
inhalations, belladonna, antipyrin, bromides, codein, trional, heroin, 
and chloral. Among the newer methods of treatment are: quinine 
given intravenously and intramuscularly, adrenalin, suggestion, and 
vaccine treatment. 

As pertussis is contagious from the very beginning of the catarrhal 
stage until the end of the spasmodic stage — a period of about ten 
weeks — it is important that children free from the disease be kept 
apart from those who have it, and in order that quarantine be effective 
all unexposed children should, if possible, be sent away from the house 
during the entire period of contagion. This applies particularly to 
infants, in whom pertussis is associated with considerable danger; 
and all children who are not robust or who have a tendency to tuber- 



PERTUSSIS 093 

culosis should be especially protected. A child with pertussis should 
not be allowed to attend school, and quarantine should be continued 
until the end of the spasmodic stage. 

All children with pertussis should be given an abundance of fresh 
air and should be kept in bed if their temperature is 100° F. or higher. 
If the patient is sufficiently ill to be in bed the windows should be 
open day and night; if not in bed the child should spend as much 
time as possible out of doors. However, as excitement and violent 
exercise increase the tendency to attacks, an effort should be made 
to keep the child interested and amused with the minimum amount 
of exertion on his part. An acute laryngitis or rhinitis is, however, 
not benefited by cold air; for such cases the air in the sick-room must 
be kept fresh but not cold. Cold, fresh air is of benefit in all other 
pertussis cases. A change of air, especially to the seashore, is often of 
benefit, and a change from a raw, damp climate to a warmer and 
milder one is often followed by improvement. 

If the child has been confined to bed any considerable time it is 
of advantage to remove him to another room and thoroughly house- 
clean the room before returning him to it. Wards where pertussis 
patients are treated should, if possible, be cleared of all patients and 
house-cleaned and fumigated before the patients return to them. 
Many cases of whooping-cough in a hospital ward suffer with mixed 
infections, and at least a temporary benefit will follow their removal 
to a recently cleaned and fumigated ward. 

All children with pertussis should be fed in small quantities and 
often, and the younger the child the more necessary it is to preserve 
its strength by proper attention to its food and digestion. If a child 
vomits soon after receiving nourishment, it should be given another 
feeding to replace the one vomited. Gastro-intestinal disorders in 
the young child suffering with pertussis often constitute a dangerous 
complication, and should receive early and careful dietetic and 
medicinal treatment. 

Local applications to the nasopharynx, if made early in the disease — 
during the first two weeks — may be of decided value. They are of 
assistance only when the infection is localized in the upper air passages, 
as in rhinitis and pharyngitis. At this period an application of 2 per 
cent, nitrate of silver solution to the nasopharynx may, by producing 
death of the superficial mucous membrane, and, possibly, destroying 
some of the specific pertussis bacilli, tend to prevent the spread of the 
infection to the deeper respiratory passages. 

Ochsenius, of Chemnitz 1 has recently reported 107 children treated 
by this method, with improvement in 84 of them. He makes the 
application every second day, and claims that eight days after the 
beginning of the treatment the number of paroxysms is slightly 
diminished and the severity of the attacks decidedly lessened, and by 
the third or fourth week improvement is marked. He lays special 

1 Therap. der Gegen., Berlin, 1913, liv, 502-509. 



691 THE SPECIFIC INFECTIOUS DISEASES 

stress on the importance of using the nitrate of silver solution early 
in the disease, when the infection is limited to the upper respiratory 
tract. Phenol (1 per cent.) has also been used successfully as a local 
application. It should be employed early and may be repeated every 
second day. 

Various drugs have been used by inhalation, particularly creosote 
and carbolic acid. They may be used in the ordinary inhaler covering 
the nose and mouth, or the vapor may be generated in the room of the 
patient. They act as a sedative to the inflamed mucous membranes 
and, at least in some degree, as a local antiseptic. As children are 
especially susceptible to carbolic acid poisoning, the urine must be 
closely watched. Chloroform may also be given cautiously by the 
physician when the paroxysms are especially severe and frequent. 
When the spasm of the glottis is unusually severe, intubation may be 
done and often gives relief. 

The medicinal treatment of pertussis may, for convenience, be 
divided into two parts: (1) drugs or other methods that per se have 
a tendency to lessen the number and severity of the paroxysms. 
(2) drugs or other methods directed to the treatment of the com- 
plications of pertussis. To the first an unusual amount of attention 
has been given; to the second, comparatively little. Among the drugs 
that per se are useful in pertussis must first be mentioned belladonna. 
Personally, I prefer using the tincture, beginning with one drop, 
three times a day, and increasing the daily quantity by one or two drops 
until mild physiological effects of the drug appear, after which the 
dose must be increased very cautiously. 

Antipyrin is a useful drug, but I have never used it in the frequent 
doses t so often advised. A single dose at bedtime, or a morning 
and evening dose, has been, in my experience, as much as it was wise 
to employ. To a child of two years I would give 2 or 3 grains each 
night, or morning and night. 

Bromide of soda, grains v, three or four times a day, to a child of 
three years, is often of benefit, and codein, trional, heroin, and chloral 
will often allay the cough and induce sleep. They may be given in a 
single dose at bedtime, or, if necessary, two or three times a day. 
A combination of quinine, two parts, and veronal, one part, has been 
used successfully by Professor Winternitz, of Vienna. He claims 
distinct improvement in 26 out of 30 children in whom he used the 
combined drugs, but believes that it acts only as long as given, and is 
not a cure. During its administration the paroxysms became milder 
and occurred less frequently ; there was less vomiting, and the appetite 
improved. Frankel and Hauptmann 1 also advise this combination 
of veronal and quinine. The dose ordinarily employed for a child of 
two years was veronal, J grain; quinine, 1 grain, repeated three or 
four times a day, according to the effect produced. They do not advise 
its use in children under six months of age. Soolman and Hatcher 2 

> Med. Klinik, Berlin, 1912, viii, 1871. 
2 Jour. Am. Med. Assn., 1908, ii, 487. 






PERTUSSIS 695 

report favorable results from a combination of quinine, grains i-ij, 
ahd bromide, grains i-ij, repeated three or four times a day, for a child 
two years of age. 

Quinine has been used in large doses and when so given may reduce 
not only the number, but also the severity of the paroxysms. It is 
not an antispasmodic, and any effect it produces in these large doses 
must be due to some effect on the causal bacillus. Lenzmann 1 has 
reported some interesting results from the giving of quinine intraven- 
ously and hypodermically. He secured very prompt and positive 
results from doses of 5 grains injected intravenously every second day. 
He claims that the paroxysms rapidly disappear and that the treatment 
acts like a charm. Quinine lactate, 10 grams; saline solution, 100 
grams, of which 2\ c.c, warm, is injected intravenously, may be 
similarly used. If given hypodermically into the muscles the effect 
is favorable, but not as prompt nor as satisfactory as when given 
intravenously. 

Hydroquinine has been employed both intravenously and intra- 
muscularly, but its action is more favorable when injected into the 
vein. It has been put up in ampules, the dose being in proportion to 
the age of the child. A daily dose was given for five or six days, then 
a dose every second day; it is claimed that marked improvement was 
perceptible after the first week of treatment. Xo disagreeable local or 
constitutional symptoms followed either the intravenous or muscular 
injections, and, as so much is claimed for this treatment, it is worthy 
of more extended trial. Hydroquinine has been used both intravenously 
and intramuscularly as a prophylactic with satisfactory results. 

Adrenalin is strongly advised in the treatment of pertussis by 
Fletcher, 2 and since the publication of his article others have reported 
favorable results following its use. Wm. J. Lord, 3 when all other 
means failed in a very delicate child, gave, by the mouth, 3TH, of a 
1 to 1000 adrenalin solution every four hours. The dose was soon 
reduced to three times a day, and the child rapidly improved; not 
only the number of the paroxysms became less, but their severity 
decidedly diminished. Carta Mulas, 4 who had read Fletcher's article, 
used adrenalin in a small epidemic of pertussis. He treated 15 cases, 
giving two to three drops of a 1 to 1000 adrenalin solution every two 
or three hours. The cough and vomiting rapidly diminished, no com- 
plications or bad effects followed the treatment, and in two or three 
weeks the patients were well. He claims that the rapid cure of these 
cases prevented the spread of pertussis, as only 5 per cent, of the 
infants contracted it. In his opinion, adrenalin exerts a specific action 
on the causal agent of pertussis. 

Kilmer, of New York City, has devised a whooping-cough belt 
which supports the abdomen, and is evidently a great comfort to the 

1 Med. Klinik, Berlin, 1912, viii, 1789. 

2 British Med. Jour., London, 1912, ii, 1784. 

3 Ibid., 1913, ii, 122. 

4 Gaz. d. Osp., Milano, 1913, xxxiv, 1295-1297. 



096 THE SPECIFIC INFECTIOUS DISEASES 

patient, for children who have once worn this belt insist on keeping 
it on during the paroxysmal stages of the disease, and like it to be 
buckled tight. In severe cases in which the paroxysms are violent, 
a plaster bandage may be applied around the ribs to give additional 
support. Some authorities encircle the chest with strips of belladonna 
plaster. If these supports are properly applied and fit snugly, they 
often modify the intensity of the paroxysms and, to a great extent, 
relieve the vomiting. 

Every close student of pertussis must be impressed with the psychic 
element that so often enters into the disease, especially in neurotic 
children. If, as often happens, the mother and those who are brought 
in contact with the nervous child are also neurotic, conditions are 
favorable for the development of marked psychic phenomena in this 
nervous child suffering from pertussis. Given a neurotic child 
in whom the psychic element is present, and suggestion may be 
advantageously used as an aid to treatment. Oberholtzer, 1 in dis- 
cussing the psychic element in pertussis, narrates the case of a boy, 
aged seven years, whose nurse, believing the paroxysms were largely 
induced by the desire of the boy to be carried in her arms, refused to 
carry him any more. His paroxysms ceased and he made a prompt 
recovery. His little sister of twenty months always began to cough 
as soon as the boy had a proxy sm. The nurse reproved her and the 
paroxysms of cough ceased. One day while taking a trip on the lake, 
and after the nurse had told the boy that if a paroxysm threatened, 
they would have to return home, his cough disappeared for four hours. 

Hamburger 2 also calls attention to this psychic element, and reports 
the case of a girl, aged three and one-half years, cured by suggestion. 
The child suffered with pertussis for five weeks and was cured in two 
days by the faradic current. Hamburger infers that in this case the 
paroxysms were pure neurosis after five weeks — what he calls a "half- 
voluntary reflex." 

Space does not permit me to discuss the treatment of the com- 
plications of pertussis, but several cases that I have seen this winter 
deserve passing mention. A boy, aged thirteen months, with a tuber- 
culous family history and himself tuberculous, passed successfully 
through a severe case of pertussis complicated with bronchopneumonia. 
In the stage of decline he became more and more drowsy, lumbar 
puncture was performed, and a clear fluid removed in which t he 
tubercle bacillus could not be found, and a guinea-pig injected with 
3 c.c. of this fluid failed to develop tuberculosis. There had never been 
any discharge from either ear, but Dr. MacCuen Smith obtained a 
drop or two of fluid by swabbing the ear with cotton. Pus was obtained 
from both ears by puncturing the drums; the day following, a double 
mastoid operation disclosed a well-advanced double mastoiditis with 
secondary otitic meningitis. The temperature had been normal for 
ten days before the operation. We all, of course, appreciate how 

1 Corr. Blatt f. Schweizer Aerzte, December 20, 1912. 

2 Wien. klin. Wchnschr., 1913, xxvi, 1869. 



PERTUSSIS 697 

latent mastoiditis may be in a child, but with no local evidence of 
mastoid disease, no discharge from the ear, and no fever, the condition 
is easily overlooked. 

Another case of interest was the seven-year-old son of Dr. C, of 
Philadelphia, who during an attack of pertussis had an unusually 
severe paroxysm on February 15. The next morning he had fever and 
vomiting. Vision continued to decline until March 13, when vision 
was found to be: left, 11/200; right, 20/100. The disks are pale; retinal 
arteries reduced in size; field of view is concentrically contracted. 
Previous high-grade double optic neuritis (choked disk). At present, 
total secondary atrophy. Disseminated choroiditis, both eyes. 
Divergence. Vision reduced to light perception. Pupils moderate in 
size and no reaction. Under ethyl chloride narcosis, pupils contract 
ad maximum. Diagnosis: hemorrhage into the sheath of nerve at the 
optic chiasm. These two cases illustrate the necessity of a correct 
diagnosis of complications in order properly to carry out appropriate 
treatment. 

The Vaccine Treatment. — I was the first to try this method of 
treatment and have carefully read the report of all cases treated by 
this method since the publication of my paper in January, 1912. A 
large number of articles have appeared upon vaccine treatment, and 
from the close study of my own series, as well as many cases seen in 
consultation where the vaccine treatment has been used, since the 
publication of my paper, I am convinced that it is a distinct addition 
to our treatment, and is also of more or less use as a prophylactic. 
In a case of moderate severity in either an infant or an older child, 
when the number of the paroxysms is small and of a mild character, 
the vaccine treatment is not necessary but it is often of distinct benefit 
in the severe cases, in children of all ages, and its influence as a prophyl- 
actic, especially where infants have been exposed, or where a frail or 
possibly tuberculous child has been infected with the pertussis bacillus, 
should be carefully investigated, and its proplylactic power tested. 
There seems to be a growing tendency to treat pertussis with a mixed 
vaccine. 

In connection with the mortality tables of typhoid fever, diphtheria, 
scarlet fever, measles, and whooping-cough, showing the number of 
deaths in Philadelplra during the five years, 1911 to 1915, inclusive, 
the following table (Xo. 1) shows the percentage of deaths to the total 
number of cases of these diseases. Table Xo. 2 may be of special 
interest; it shows the number of deaths in Pennsylvania from the 
above diseases during the years 1909-1912, inclusive, in children 
under one year of age, in children under five years of age, also at all 
ages, as well as the total mortality in Pennsylvania from all diseases 
during these years. Table Xo. 3 shows the mortality in Pennsyl- 
vania, during the years 1911 and 1912, from the diseases tabulated,, 
embracing the number of deaths at all ages, also the mortality in chil- 
dren under five years of age. 



698 



THE SPECIFIC INFECTIOUS DISEASES 






Table 1 . — Table Showing Percentage of Deaths to Total Number of Cases 

of Measles, Diphtheria, Scarlet Fever, Whooping-cough, And Typhoid 

Fever in Philadelphia from 1911 to 1915, Inclusive. 



Number of cases. 


Total 

No. of 

cases 

in 5 years. 


Total 

No. of 

deaths 

in 5 years. 


Percentage 

of deaths 

to total 

No. of cases 
in 5 years. 




1911. 


1912. 


1913. 


1914. 


1915. 


Measles .... 
Diphtheria . 
Scarlet fever 
Whooping-cough 
Typhoid fever . 


11,640 
3,792 
1,928 
1,410 
1,382 


2,279 
3,080 
2,872 
1,369 
1,514 


15,611 
2,623 
3,400 
1,438 
1,698 


7,098 
2,610 
1,944 
4,152 
793 


14,089 
2,615 
1,072 
1,092 

787 

Total 


50,715 

14,720 

11,216 

9,461 

6,174 


798 
1,741 
608 
655 
911 


1.5+ 

11.8 

5.4 

7.0 
14.7 




92,286 


4,713 





Table 2. 



State of Pennsylvania. 
Total mortality, 1909, from all diseases . 
" " typhoid fever 
" " diphtheria 
" " scarlet fever 

" " measles . 
" " whooping-cough 

1910, from all diseases . 
" " typhoid fever 
" " diphtheria . 
" " scarlet fever 
" " measles . 
" " whooping-cough 

1911, from all diseases . 
" " typhoid fever 
" " diphtheria . 
" " scarlet fever 
" " measles . 
" " whooping-cough 

1912, from all diseases . 
" " typhoid fever 
" " diphtheria . 
" " scarlet fever 
" " measles . 
" " whooping-cough 



At all 
ages. 

111,062 

1,712 

2,002 

1,216 

1,060 

910 

119,815 

1,892 

2,235 

1,094 

1,237 

1,114 

111,292 

1,716 

2,111 

749 

804 

998 

111,842 

1,310 

2,042 

552 

845 

809 



Under 
one year. 

25,638 

8 

139 

72 

286 

500 

28,377 

3 

178 

64 

306 

581 

24,195 

4 

122 

46 

202 

567 

24,110 

8 

146 

34 

202 

476 



Under 
five years. 

36,216 

87 

1,350 

754 

934 

870 

40,495 

77 

1,443 

657 

1,083 

1,068 

33,788 

66 

1,346 

460 

704 

960 

33,468 

51 

1,371 

337 

735 

777 



Table 3. 



1911. 

Mortality in State of Pennsylvania. 

All ages. Under 5 years. 

Acute anterior poliomyelitis ... 93 61 

Convulsions of infants .... 1062 
Diarrhea and enteritis (infantile) .8156 

(Under 2 yrs.) 

Rickets 69 63 

Congenital malformations . . . 1345 1319 

of heart . 881 862 

Injuries at birth 552 552 

Congenital debility, icterus, and 

sclerema 5942 5942 

Diseases of spleen 14 2 

Hernia, intestinal obstruction . . 855 174 

Pneumonia 3573 1525 



1912. 



All ages 

116 

960 

7469 

(Under 2 yrs.) 

90 

1389 

877 

593 

6420 

10 

930 

7130 



Under 5 years. 

78 



87 

1368 

867 

593 

6420 

1 

191 

2352 



MUMPS 699 



MUMPS (EPIDEMIC PAROTITIS). 

Mumps is an infectious disease, characterized by swelling of the 
salivary glands, particularly the parotid gland, together with mild 
constitutional symptoms. 

Etiology. — It has not been proven to be due to any one type of 
organism, but Catlin and Laveran have isolated from the blood and 
glandular lymph of the parotids and testes a diplococcus which pro- 
duced parotitis in dogs and monkeys when injected into Steno's 
duct. An intracellular diplococcus has also been isolated from Steno's 
duct, and it is generally believed that the infection enters the parotid 
from the mouth by way of this duct. 

The mode of infection is usually by direct contact, though it is 
possible to convey the infection by a third person or by clothing. It 
occurs endemically in large cities, particularly in spring and autumn. 
It is more common in boys than in girls. Children between the ages 
of three and ten years are more susceptible than young infants and 
adults. Owing to the fact that the disease is communicable for several 
days after the subsidence of the swelling, such children should be 
isolated for a period of at least three weeks from the date of onset. 
The period of incubation is from ten days to three weeks, and during 
this time there are rarely any symptoms of the affection. 

Morbid Anatomy. — Owing to the trivial nature of this disease, there 
has been little opportunity to note the pathological changes which take 
place; but there is, as a rule, simply a serous infiltration which usually 
ends in resolution. Suppuration is very rare. 

Symptoms. — There is usually a prodromal period during which 
the child is chilly and may vomit; following this the acute symptoms 
appear, varying in character and intensity according to the severity 
of the attack. The onset is usually marked by fever ranging from 
100° to 101° F., headache, anorexia, vomiting, and pains in the back 
and legs. Pain on swallowing or moving the jaw may be the first 
objective symptom, and the child complains of pain beneath the ear. 
A slight swelling begins, usually on one side, which reaches its height 
on the second or third day, remains stationary for two or three days, 
and then gradually subsides. The swelling causes the lobe of the 
ear to be lifted and passes forward in front of the ear and backward 
to the sternomastoid muscle. The other salivary glands, the sub- 
maxillary and sublingual, are often not involved or they may at the 
same time show evidence of swelling, or may not become enlarged 
until after the parotid swelling has completely disappeared. More 
frequently both parotid glands become involved, but not simultane- 
ously; the inflammation appears in one, and the maximum swelling 
is reached in forty-eight hours, after which the other side becomes 
involved, and swells with equal rapidity. When one alone is affected, 
it is more often the left than the right. During the height of the disease 
the mouth becomes dry, the salivary secretions are diminished, and 
there is excessive pain on swallowing. Mastication is both difficult 



700 THE SPECIFIC INFECTIOUS DISEASES 

and painful, and in extreme cases it may be almost impossible to open 
the mouth because the parts are so tense and swollen. In young infants 
there is drooling. There may be earache, otitis media, and frequently 
also slight impairment of hearing. In the more severe cases there 
may be high fever, ranging from 103° to 104° F., delirium and marked 
prostration. Relapses are rare, but cases of recurrent mumps have 
been reported which persisted for six weeks. 

Diagnosis. — The diagnosis is usually easy, though the disease may 
be confused with acute swelling of the cervical lymph nodes. The 
latter is usually behind the jaw, and does not extend to the face. In 
swelling of the parotid gland, the lobe of the ear on the affected side 
becomes elevated, and occupies the centre of the tumefaction, the 
swelling extending in front of and below the ear. The rapidity of the 
swelling and its short duration are characteristic of mumps. Inflam- 
mation of the parotid is usually, but not invariably, due to mumps; 
a history of other cases in the vicinity, is additional evidence in favor 
of true mumps. 

Complications. — In childhood complications are rare, but in puberty 
orchitis may occur, usually making its appearance between the second 
and third weeks of the disease, and occurring most frequently in those 
who are allowed to be up and about. Either one or both testicles 
may become involved and the swelling is marked. Usually the testicle 
proper and not the epididymis is affected ; but occasionally there may 
be acute epididymitis, acute hydrocele, edema of the scrotum, or 
inflammation of the spermatic cord and inguinal glands. Frequently 
it is accompanied by fever and chills, and the testes are painful and 
heavy. 

The acute symptoms continue for from three to seven days, though 
frequently the testicle remains enlarged for some time afterward, 
and the swelling persists even longer when the parotitis is bilateral. 
Atrophy of the testes with resulting sterility has been reported as 
following mumps. 

In some cases the urine contains a trace of albumin. Urination may 
be painful, and there may be a urethral discharge. In females there 
may be congestion of the breasts, ovaries, and labia majora, though 
such complications are not at all common. 

The thyroid gland may show some enlargement during the attack. 
Delirium and high fever are occasionally observed, coma may appear, 
more rarely there is acute mania, and, in exceptional instances, insanity. 
Hemiplegia may occur, and in rare cases meningitis. Suppuration 
of the parotid gland is rare, and when it occurs is probably the result 
of a mixed infection. 

There may be disturbances of the special senses, such as deafness 
and optic neuritis. Nephritis has in some cases followed an attack. 
Pneumonia, endocarditis, and pericarditis occur in rare instances. 
As a rule complications do not appear until after the parotitis has 
subsided. Parotitis itself may be a complication of pneumonia, 
influenza, measles, varicella, or typhoid fever. 



INFLUENZA 701 

Course and Prognosis. — In the vast majority of instances mumps is a 
mild disease, from which complete recovery takes place in a few days, 
and the disease generally runs its course in a week or ten days. Severe 
cases are rare ; if uncomplicated, the prognosis is very favorable. When 
such complications as edema of the glottis, suppuration of the parotid, 
or meningitis occur, the outlook becomes serious; but involvement of 
the testicles or ovaries and of the mammary glands, while painful, is 
rarely dangerous. 

Treatment. — Usually little or no treatment is necessary. The patient 
should stay in bed for at least one week. The bowels can be opened 
freely by an initial dose of 1 to 3 drams of castor oil, after which the 
aromatic syrup of rhubarb, 1 to 2 drams, or the aromatic fluidextract 
of cascara sagrada, 20 to 40 drops, may be administered whenever 
necessary. The patient should be kept upon liquid diet for a week. 
If the fever is high, 5 to 10 drops of sweet spirits of nitre may be given 
every three hours, or the temperature may be reduced by sponging 
the child in water at a temperature of 75° to 85° F. Hexamethyl- 
enamin should be given in 1- to 2-gram doses, three times a day. 

If pain is severe, 1 to 2 grains of Dover's powder may be combined 
with 3 grains of salol or 1 grain of phenacetin, and administered every 
four hours until the child is relieved. 

It is advisable to keep these children warm, and to prevent any 
chilling of the body throughout the whole course of the disease, since 
this will expedite recovery, and also because it is believed that com- 
plications may be induced by sudden chills. 

Locally either cold or hot applications may be used on the gland; 
usually the latter are more agreeable; they should be covered with a 
pad of cotton wadding, and over this oiled silk. Relief will often be 
afforded by anointing the gland with some simple ointment, such as 
cold cream. 

For severe pain warm oil of hyoscyamus may be applied twice daily, 
or 25 per cent, ichthyol, or such remedies as witch hazel, lead-water 
and laudanum, or menthol may be employed locally. The mouth 
should be frequently cleansed with liquor alkalinus antisepticus, 
25 per cent, dilution, in order to prevent infection of the gland through 
the duct. Children suffering with mumps should be isolated and kept 
apart from other children for a period of not less than three weeks. 

Should orchitis develop, rest in bed, together with support of the 
affected testicle with cotton-wool and adhesive straps, will usually 
suffice. 

INFLUENZA (LA GRIPPE: CATARRHAL FEVER). 

Influenza is an acute infectious disease characterized by a catarrhal 
inflammation of the mucous membrane, particularly of the respiratory 
tract, together with fever, muscular pain, and marked prostration. 

Etiology. — The bacillus of Pfeifi'er, discovered in 1892, is found in 
the sputum and nasal discharges. It is 0.8 to 1 micron in length, and 



702 THE SPECIFIC INFECTIOUS DISEASES 

0.1 to 0.2 micron in breadth. In glycerin agar it forms colonies, which, 
under the microscope, appear as clear, separate drops. They are best 
stained by hot Loeffler methylene blue solution, or dilute solution of 
Ziehl-Neelson carbol-fuchsin. The bacillus is easily transmitted from 
one individual to another, because of its presence in the sputum and 
nasal discharges. Other organisms associated with the bacillus of 
PfeifTer are the Streptococcus and Diplococcus pneumoniae. 

Influenza occurs epidemically, but after epidemics may remain 
endemically for some time, although in the majority of endemic cases 
of influenza it is impossible to isolate the PfeifTer bacillus. The diplo- 
coccus of Frankel, however, is quite commonly found in these cases, 
therefore it is often called pneumococcus grippe. Epidemics usually 
occur during the winter and spring. 

The disease also appears in pandemics. This form is not as common 
in children as in adults, but the endemic form of influenza, which is 
encountered at all seasons of the year, and the development of which is 
favored by sudden and great changes in temperature, is very prone 
to attack children. The disease is rather uncommon in infants, but 
children between the ages of two and ten are very apt to contract it. 
One attack does not confer immunity against a second, and some 
children have it every winter. Among the predisposing factors in 
the endemic form of influenza are exposure to cold and lowered vitality 
from malnutrition, exhausting illness, or other debilitating influences. 

The period of incubation is supposedly short, ranging from two to 
seven days. The chief complications are pneumonia, pleurisy, and 
endocarditis. 

Two types of influenza are recognized: epidemic influenza vera, 
caused by the bacillus of Pfeiffer, and endemic influenza vera, which 
appears for several successive years after a pandemic. 

Morbid Anatomy. — Our present knowledge of the pathological 
changes caused by influenza is very scant, for whatever alterations are 
produced by this disease promptly disappear at death. There is, 
however, an inflammation of the mucous membrane of the upper 
respiratory tract, and in severe cases the trachea, bronchi, and peri- 
bronchial tissues may also be affected. The remaining pathological 
changes are due to the complications, such as bronchopneumonia, 
otitis media, meningitis, and empyema. In infants there may be 
catarrhal inflammatory changes in the mucous membrane along the 
gastro-intestinal tract. 

Symptoms. — The symptoms of influenza in children vary greatly, 
according to the severity of the attack. If mild, the onset is usually 
sudden, and the attack lasts about a week. Coryza, sneezing, and 
watering of the eyes are usually the first symptoms to make their 
appearance, and these are followed by chills, and coughing with 
profuse expectoration. The throat and nares are red and injected, and 
the tonsils are frequently covered with mucus, and studded with a 
yellowish deposit. The cough is loud, harsh, painful, and sometimes 
very persistent. 



INFLUENZA 703 

Muscular pain is more or less constant, and may often be the 
first symptom of the illness, manifesting itself in the back, extremities, 
and head, so that the child cries with pain when picked up or moved 
about. Vomiting may occur. The temperature range is from 101° 
to 103° F. There is usually associated pharyngitis and bronchitis, 
and prostration is always quite marked. In infants early involvement 
of the gastro-intestinal tract is shown by green stools, diarrhea, loss 
of appetite for breast or bottle, and colicky pains in the abdomen. 
Older children become nauseated and constipated, and complain of 
epigastric pain. 

In the more severe types of influenza the onset may be extremely 
sudden, and prostration great. Fever, though mild at first, may run 
exceedingly high, from 102° to 105° F. and even 106° F. At this 
time delirium may occur, and nervous symptoms become prominent. 
The child usually lies in a drowsy, stuporous state, and although 
convulsions are rare, musclar twitchings are not uncommon. The pulse , 
rate is usually accelerated, and corresponds with the degree of tempera- 
ture. 

In children the attack may be preceded by severe vomiting, and 
sometimes diarrhea; but the symptoms and physical signs are not as 
severe as one would expect with the degree of fever, although pros- 
tration is profound. Follicular tonsillitis frequently accompanies 
this class of cases, and pneumonia is a common complication. The 
moderately severe cases terminate in six to ten days, but occasionally 
influenza assumes a chronic form, in which the temperature and other 
symptoms persist for several weeks. 

In endemic grippe, especially, there is usually a slight trace of 
albumin in the urine, and the kidneys may become involved, actual 
nephritis being indicated by a decrease in the quantity of the urine, 
and the presence of blood and casts. There is no edema, but the 
persistence of albuminuria for weeks and months denotes a low-grade 
nephritis. 

In very severe cases of influenza, a bacillus may be found in the 
blood stream, and meningitis and arthritis are not infrequent accom- 
paniments. According to the predominating symptoms, the disease 
in the adult is classified as respiratory, nervous, gastro-intestinal, or 
febrile influenza; but in the child this distinction is not quite so 
definite for the symptoms are often irregular. In some children the 
gastro-intestinal, respiratory, and nervous forms may occur one after 
the other. 

Respiratory Form. — In the respiratory type the entire tract becomes 
the seat of the disease. The onset is marked by coryza and evidences 
of acute catarrhal fever. In some cases bronchitis follows the catarrhal 
symptoms, there is a steady increase in the fever, delirium may appear, 
together with profound prostration. Pharyngitis, tonsillitis, and 
laryngitis are prominent features of the respiratory form of influenza, 
and latent pulmonary tuberculosis may again become active in con- 
sequence of the attack. 



704 THE SPECIFIC INFECTIOUS DISEASES 

The expectoration is copious, and contains masses' of purulent 
material; sometimes the sputum may be bloody and of a dark red 
color. The most serious complication is pneumonia, which is most 
frequently lobular in type. It may set in after several days of severe 
bronchitis and high fever, the smallest bronchi gradually becoming 
involved, or it may develop suddenly. In the majority of cases 
pneumonia is due to the pneumococcus, and clears up readily, but in 
some instances it rapidly proves fatal. The outcome depends to a 
great extent upon the virulence of the organism, and the resistance and 
vitality of the child. Pleurisy may occur, but is rare. 

Nervous Form. — This type is marked by the absence of catarrhal 
symptoms, and manifests itself by pains in the back, chest, and extremi- 
ties, intense headache, and extreme prostration. These children are 
very irritable and restless, but may become stuporous. Occasionally 
convulsions occur, but severe nervous manifestations are noted only 
in the worst forms of influenza. Rigidity of the muscles of the neck, 
muscular twitch ings, paresthesia, and dizziness may be observed. 
Many cases in which nervous symptoms are conspicuous are accom- 
panied by pneumonia. The chief complications are meningitis and 
encephalitis, but, in fact, almost any type of nervous disease may 
complicate an attack of influenza. 

G astro-intestinal Form. — In this type nausea and vomiting pre- 
dominate, together with abdominal pain and diarrhea, all of which 
have a tendency to cause collapse. Malnutrition is severe and, 
together with the extreme prostration which accompanies grippe, 
results in exhaustion and emaciation which are often the forerunners 
of collapse. Gastro-intestinal symptoms usually predominate in very 
young children, and in infants there may be enlargement of the spleen. 

Febrile Form. — Here fever may be the only clinical manifestation 
of the disease, and may be accompanied by chills, and t be remittent 
in type; or, again, the fever may be continuous, and closely resemble 
typhoid fever. 

Diagnosis. — Epidemic grippe is, in the majority of cases, easily 
diagnosed, but mild sporadic cases may present some difficulty until 
carefully studied. The profound prostration which is out of all 
proportion to the other clinical manifestations, together with the 
suddenness of onset and short duration of the fever, will usually point 
to the diagnosis. 

The nervous symptoms may arouse a suspicion of meningitis, but 
true symptoms and signs of meningeal inflammation are lacking; 
and the onset of pneumonia in this class of cases is very significant 
of grippe. 

In rare cases influenzal meningitis may be present and can be 
demonstrated by examination of the cerebrospinal fluid which contains 
the bacilli. Pneumococcic and cerebrospinal meningitis are, to a great 
extent, differentiated from the influenzal type by the bacteriological 
findings, for the symptoms are not widely different. 

The high fever and cough with a history of chills may simulate 



INFLUENZA 705 

pneumonia, but careful examination of the chest will exclude this, 
except when pneumonia is present as a complication. At the onset 
of influenza both scarlet fever and measles may be simulated by the 
pharyngitis, coryza, injected conjunctiva, and bronchitis, and in these 
cases the differential diagnosis is occasionally rendered even more 
difficult by the appearance of a rash on the skin. An accurate history 
and careful study of such cases for two or three days will generally 
clear up the diagnosis. 

In the subacute type of influenza the symptoms may to some 
extent resemble those of typhoid fever, and this is especially the case 
in prolonged attacks with continued fever, but the Widal reaction will 
be found negative, there are no rose spots, nor is there any marked 
enlargement of the spleen. 

The presence of the influenza bacillus in the sputum may be deter- 
mined microscopically early in the disease, but a bacteriological diag- 
nosis of influenza, while very valuable, is too difficult to be resorted 
to in most cases. 

Complications. — Pneumonia is by far the most serious complication 
of influenza, and may be associated with pleurisy and empyema. 
Endocarditis and pericarditis, together with irregularity of the heart — 
tachycardia and bradycardia — may also set in, and meningitis and 
encephalitis are sometimes sequels. Influenzal meningitis is marked 
by symptoms of meningeal inflammation; the cerebrospinal fluid 
is cloudy, and contains an increased number of polynuclear cells. 
Upon microscopic examination of the cerebrospinal fluid the bacilli 
are seen to be both intracellular and extracellular. This complication 
usually results in death. Acute otitis media is a frequent complication, 
and may result in mastoiditis and sinus thrombosis. Phlegmasia alba 
dolens, caused by venous thrombosis, has occurred in several instances. 
Cervical adenitis with involvement of the parotid and submaxillary 
glands is not uncommon. 

Skin rashes may appear during the course of the disease, although 
no one eruption is characteristic of influenza. Among the various 
skin lesions which may be noted are herpes facialis, herpes zoster, 
erythema papulatum, urticaria, and a scarlatiniform erythema which, 
to a certain extent, resembles the rash of both measles and scarlet 
fever. Secondary anemia usually follows an attack of influenza, and 
some observers have noted an increase in the number of cases of 
appendicitis during epidemics of influenza. 

Cystitis frequently follows grippe, especially in little girls, and 
influenza may either give rise to rheumatic symptoms or cause an 
acute exacerbation of rheumatism in children who already suffer from 
this disease. Influenza has a tendency to stir into activity any latent 
form of disease; this is particularly true of latent tuberculosis. 

Prognosis. — The prognosis is usually favorable, provided the patient 

does not take cold during the attack, and thus bring on that dangerous 

sequel, pneumonia, as well as other complications. In infants who have 

influenza there is often serious involvement of the intestinal tract, 

45 



706 THE SPECIFIC INFECTIOUS DISEASES - 

and as pneumonia is a common complication in the younger child, 
the prognosis is more serious in infants and very young children than 
it is in later childhood. Death may also be the result of toxemia and 
exhaustion, especially when a severe attack of influenza occurs in a 
child whose general health is undermined by malnutrition or some 
constitutional disease, such as tuberculosis or syphilis. Influenza 
attacks strong healthy children, as well as weaklings, and the mortality 
among children varies to a certain extent in different epidemics. 

Treatment. — All cases should be isolated because of the contagious- 
ness of the disease, and after recovery the sick-room should be fumi- 
gated. Children should immediately be put to bed, and remain there 
until after the attack has subsided, when they may be allowed to 
play about in one or two rooms from which the other members of the 
family are excluded. The bowels should be freely opened by the use 
of castor oil, 1 dram to \ ounce, or some other purgative, such as mag- 
nesium citrate, 2 to 6 ounces, or magnesium sulphate, 1 to 2 drams. 
If, in infants, there is diarrhea, they should also be given an enema, 
and no milk should be allowed until improvement takes place. In 
its place albumen-water, oatmeal gruel, rice- or barley-water, or beef 
juice may be given at frequent intervals, the amount depending upon 
the age of the child and severity of the symptoms. 

Fever should be combated by sponging or by a tepid bath with the 
water at about 98° F. Following the bath the child should be well 
rubbed. An ice-bag may be kept upon the head, and in some cases 
it affords relief if applied to the chest, being moved about every 
half-hour. 

The nervous symptoms accompanying the disease should be con- 
trolled by the use of phenacetin, 2\ grains night and morning, or 
Dover's powder, J to 1 grain, or codein sulphate, -^ to 2V °f a grain. 
Should there be cardiac weakness nothing is quite so efficient as 
alcoholic stimulation, and 10 to 30 drops of whisky or brandy may be 
given every three hours, if necessary. Other cardiac stimulants 
which may be used are strychnine and digitalis, -4^ to 2 \-$ of a grain of 
strychnine sulphate, and 1 to 3 drops of tincture of digitalis (or y-g- to 
\ grain of strophanthus) may be administered every three hours. 

In older children the use of quinine sulphate, \ to 1 grain, is of decided 
benefit, particularly if combined with either phenacetin, 1 grain, or 
Dover's powder, 1 grain, and given every six hours. Its use in infants 
is not so highly recommended because of its tendency to upset the 
stomach. 

The cough which accompanies influenza may be relieved by the use 
of codein sulphate, yV to T V °f a grain, or heroin hydrochloride, ^ to 
-2V of a grain three times a day, the dose of these drugs depending 
upon the age of the child. Much can be done to prevent pneumonia 
and otitis, as well as other complications, by spraying the nasopharynx 
two or three times daily with a saturated boric acid solution or normal 
saline. When the cough lasts for some time after an acute attack, 
it is best combated by the use of cod-liver oil, to which is added 5 drops 



SMALLPOX 707 

of creosote to the ounce, and \ to 1 dram of this may be given two or 
three times daily. 

The diet should be carefully regulated. All children who have any 
tendency to pulmonary disease, particularly tuberculosis, should be 
carefully guarded, and they should, if possible, if the attack occurs 
during the winter months, be removed to a mild and equable climate. 
Such winter resorts as Brown's Mills in the Pines, or Old Point ( 'omfort, 
provide an ideal climate for convalescence in these cases. 

In influenzal meningitis, the use of the specific serum which has now- 
been placed on the market is strongly urged, since it bears the same 
relation to the disease, and is of the same significance, as is Flexner's 
serum in cerebrospinal meningitis. 

SMALLPOX (VARIOLA). 

Smallpox is an acute infectious disease, characterized by an erup- 
tion of the skin which passes through successive stages of papule, 
vesicle, pustule, and crust. 

History. — It is believed to have existed in China at least a thousand 
years before the Christian era. It was imported into this country 
in the latter part of the sixteenth century by the Spanish. In 910, 
Rhazes wrote the first description of smallpox, and it was first dis- 
tinguished from measles by an Arabian physician, Avicenna by name. 

Etiology. — Natural immunity to the disease is rare, and those 
exposed, unless protected by vaccination, are almost certain to be 
attacked. In the majority of instances, one attack protects against a 
second, though second and even third attacks have been reported. 
It is exceptionally fatal in children under ten years of age, but may 
affect persons of all ages. A pregnant mother may contract the disease, 
and the fetus in utero be attacked at the same time. Males and 
females are equally affected. Negroes are particularly susceptible, 
and the mortality among them is greater than in the white race, 
the ratio being almost two to one. In temperate climates it is looked 
upon as a cool weather disease, and in tropical countries is regarded 
as a hot weather malady which ameliorates as cooler weather 
approaches. Once implanted in a community, the disease rapidly 
spreads, but the virulence of epidemics in different localities varies 
greatly. In the United States the disease is steadily on the decrease, 
as it is in all other countries where vaccination is practised. 

Contagion. — There is no doubt that smallpox is the result of infection 
by a specific organism, and that this organism is present in the blood 
has been proven by inoculating a monkey with blood from a person 
suffering with the disease. It is also present in the pustules, the pus 
from these, when inoculated into a human being, producing smallpox. 
Unquestionably also it is present in the exhalations, and the infection 
may be carried by a second person or by the atmosphere. Clothing 
and other articles which have come in contact with the patient may 
also be a means of conveying infection. 



708 THE SPECIFIC INFECTIOUS DISEASES 

The period in which smallpox is most contagious is during the stage 
of suppuration and early dessication. A case has been recorded by 
Austin Flint in which the contagion was spread by a cadaver. Domestic 
animals and insects may also transmit it. In most cases the disease 
is contracted by direct contact, and such contact need not necessarily 
be for any great length of time, inasmuch as the slightest exposure to 
smallpox is often followed by an attack. The severity of the illness 
in one person does not necessarily imply that other individuals, who 
contract the disease from having come into contact with him, will 
have a severe attack, for the disease when acquired from one suffering 
with it in virulent form, such as hemorrhagic smallpox, is often 
exceedingly mild, and the reverse may also be true. 

The nature of the contagion is not definitely known, although 
Councilman has described a protozoon which gains entrance into the 
nuclei of the epithelial cells, and causes the formation of minute 
vacuoles about a central vacuole. The life-history of the organism 
has been further studied, and its relation to the skin lesions of smallpox 
give the impression that it is the actual cause of the disease. 

Pathology. — In some cases the mucous membrane of the mouth 
and pharynx is the seat of pustules, and, indeed, there have been 
instances where the rash has extended down the esophagus and into 
the stomach. It may also involve the trachea and bronchi; and, 
although no true pocks are found in the bronchi, bronchitis, broncho- 
pneumonia, lobar pneumonia, and pleurisy are occasionally associated 
with it. The spleen becomes greatly enlarged, and the kidneys fre- 
quently are the seat of cloudy swelling; often minute areas of necrosis 
may be seen. The heart may be the seat of myocardial changes, 
chiefly of a parenchymatous or fatty nature. In the hemorrhagic 
form of the disease the serous and mucous surfaces and parenchyma 
of various organs become the seat of extravasations. At times there 
is hemorrhage in the bone-marrow. 

Histologically the pustule begins in the rete mucosa, and consists 
of a central area of coagulation necrosis, surrounded by an infiltration 
of leukocytes together with serum and fibrin. In the more severe 
forms of pustule, infiltration extends into the papillse of the skin, 
causing their destruction, which terminates in the formation of a 
pit. 

Symptoms. — The types of smallpox described are: 

1. Variola vera. 

(a) Discrete. 
(6) Confluent. 

2. Variola hemorrhagica. 

(a) Purpura variolosa. 

(6) Variola hemorrhagica pustulosa. 

3. Varioloid — smallpox modified by vaccination. 

The period of incubation is usually from seven to fourteen days. 
The onset is sudden, accompanied by severe headache and backache, 
which in adults are sometimes preceded by a chill. In children the 






SMALLPOX 709 

only initial symptom may be a convulsion. Fever follows, often reach- 
ing- 103° to 104° F. during the first twenty-four hours. The pulse 
becomes rapid and bounding, and at this stage there is frequently 
delirium. Constipation and persistent vomiting may become prom- 
inent. Usually a violent frontal headache, vertigo, and severe pains 
in the lumbar region are complained of. 

The initial rash makes its appearance on the second day, either as a 
diffuse scarlatinous or a measly form, and covers a certain portion 
of the body surface, though it is usually confined to the abdomen, 
the inner surface of the thighs, and the axillae. On or about the fourth 
day small red spots make their appearance, first on the forehead 
and wrists, followed by rapid extension over the face, abdomen, and 
extremities. Within another twenty-four hours these papules acquire 
a characteristic shot-like hardness, and at this time there is an amelio- 
ration of symptoms — namely, a drop in temperature and general 
relief from the violent headache and backache. On the sixth day 
the papules become vesicular and depressed, thus forming what is 
known as the umbilication, which is extremely characteristic of the 
smallpox eruption. The fluid in the vesicle increases in turbidity 
until about the eighth day, when it becomes intensely yellow and the 
umbilication disappears, thus forming a pustule. 

At this time there is a return of fever and, because of the tension 
about the eruption, some degree of pain in these parts. On or about 
the eleventh day the pustules begin to dry, and this continues until 
the fourteenth day, when crusts are formed which fall off, leaving 
either a slight discoloration, as in the milder types, or an ulcer, or a pit, 
according to the degree of cicatrization. By this time the secondary 
fever has about disappeared. 

Many variations of the eruption may be noted, the preceding 
description being that of the usual simple or discrete variety. When 
the pustules are in close proximity, they may unite, thus producing 
the confluent variety, and when accompanied by bloody infiltration 
the term hemorrhagic smallpox is used. 

In the confluent type of the disease, the eruption usually makes its 
appearance earlier than in the discrete form, that is, on the third day. 
The symptoms are usually aggravated, and there is no abatement of 
the fever when the rash appears, as is the case in the discrete form. 
In the confluent form of the disease we may sometimes see enormous 
pus vesicles, some part of which may be dry as the result of early 
rupture here and there. In the more severe cases of this type extreme 
exhaustion makes its appearance on or about the tenth day, and 
frequently brings about a fatal termination. 

The hemorrhagic form of the disease is even more severe than the 
confluent. Two types are described. The first is purpura variolosa, 
in which hemorrhage makes its appearance early in the form of a 
hemorrhagic rash, together with hemorrhage from the mucous surface 
which often occurs as early as the second or third day. Death usually 
soon follows. In the second form, known as variola hemorrhagica 



710 THE SPECIFIC INFECTIOUS DISEASES 

pushrfosa, the disease follows the usual course until the vesicular or 
pustular stage is reached, when hemorrhagic symptoms manifest 
themselves by the appearance of blood in the pocks. 

VARIOLOID. 

This variety, which is variola modified either by vaccination or a 
previous attack of smallpox, is characterized by the extreme mildness 
of its symptoms, and by early convalescence. The fever is less, and 
the eruption exceedingly light, sometimes failing to show its successive 
stages. Usually the interval between vaccination and the attack is 
the factor which determines the severity; that is, the longer the 
interval between the two, the more severe the disease is apt to be. 

Abortive Types. — Various modifications of smallpox may be noted in 
different epidemics. In un vaccinated children there may sometimes 
be but a few pustules, and the disease may terminate uneventfully 
in a few days; again the vesicle may, instead of becoming filled with 
pus, dry and disappear, giving rise to the so-called wart-pox. Another 
form, known as variolce sine variolis may be seen in which all the 
symptoms of the disease are present except the eruption; such cases 
are not numerous. 

Diagnosis. — Vomiting preceded by a chill and accompanied by 
severe headache and backache should arouse suspicion, particularly 
so if there is a history of exposure to smallpox. When the eruption is 
typical, the diagnosis is easily made, for in no other disease do we 
find such a profuse pustular eruption as in smallpox; but in mild cases 
and those modified by vaccination the diagnosis is sometimes a matter 
of great difficulty. Much importance should be attached to a history 
of exposure, to the presence or absence of a recent and good vaccination 
mark, and to the visible signs of a preceding attack of smallpox. A 
positive diagnosis is scarcely possible before the appearance of the rash. 
The primary rash might be confused with that of scarlet fever or 
measles, but other symptoms of the two latter diseases ought to aid 
in the differentiation. 

The constitutional symptoms of smallpox are, however, more severe 
than those of measles, and in variola the fever declines before the 
appearance of the eruption, while in measles the temperature is usually 
at its height at the time of the eruption. In smallpox there is no 
prodromal catarrhal inflammation of the upper respiratory tract, and 
the eyes are not inflamed. Koplik's spots are not seen in smallpox. 

Scarlet fever may be differentiated from smallpox by the prodromal 
rash, sore throat, and the absence of severe lumbar pains. The symp- 
toms of the two diseases are also essential points in the differentiation. 
In the malignant hemorrhagic type of the disease, death may occur 
prior to the appearance of the characteristic eruption, and in such cases 
it is extremely difficult to distinguish it from hemorrhagic scarlet fever 
and hemorrhagic measles. 

The disease with which smallpox is most frequently confounded 



VARIOLOID 711 

is varicella, and this occurs most often when the disease assumes a 
mild form. The most valuable points in the differentiation of the two 
diseases are as follows: 

In varicella the prodromal symptoms are not as intense as in small- 
pox. It is more apt to occur in children than in adults. The rash is 
most abundant about the trunk, and it appears in crops. The papules 
do not have a " shot-like" feeling, the vesicles are superficial, and 
ruptured by the slightest pressure. There is little or no infiltration 
about the pocks. Finally, the presence or absence of a good vac- 
cination mark is a determining factor in making the differential 
diagnosis. 

Pustular syphilid may be confounded with the disease, particularly 
if accompanied by fever; but the absence of, or merely a slight, rash 
on the face in syphilis, together with the history of a primary lesion 
in adults, or a Wassermann reaction, should be our guide. 

Confusion may also arise in differentiating the hemorrhagic variety 
of the disease from cerebrospinal fever. The eruptions of acne, eczema, 
syphilis (pustular), and vaccinia have, in a few instances, been con- 
fused with the eruption of smallpox. 

Complications.— Among these are laryngitis followed by fatal edema 
of the glottis, necrosis of the cartilages, and bronchopneumonia 
induced by the aspiration of particles into the lower air passages 
owing to the diminished sensibility of the larynx. Almost all of the 
fatal cases show evidences of bronchopneumonia. 

Cardiac complications are also seen in the form of myocarditis 
and pericarditis, more rarely endocarditis. During the height of the 
primary fever a systolic murmur may sometimes be heard at the apex. 
Of complications in the digestive system, diarrhea is in all probability 
the most frequent, especially in children. Nephritis is rare, although 
albuminuria is frequent. Occasionally there may be inflammation 
of the ovaries and testes. The skin may be the seat of boils, acne, and 
ecthyma, and occasionally of small areas of gangrene. Violent con- 
junctivitis may result from neglect of the eyes, and there may be 
a diffuse keratitis. Otitis media may result from extension of the 
disease by way of the Eustachian tubes. 

Complications of the nervous system may be serious. The delirium 
so common during the early stages of the disease may increase in 
intensity, and be prolonged indefinitely, until it results in fatal coma. 
Insanity occasionally develops during convalescence. 

Arthritis may make its appearance during the stage of desquama- 
tion, and may terminate in suppuration. 

Prognosis. — Age, race, and the type of the epidemic are the chief 
determining factors in the death-rate. The mortality is extremely 
high in the young. In the epidemic which occurred in Montreal, 
in 1885, 86 per cent, of the total number of deaths occurred in children 
under ten years of age. The average mortality is from 25 to 35 per 
cent. The mortality of varioloid is much lower, ranging from 10 per 
cent, in infancy to 5 per cent, in older children. Complications, such 



712 THE SPECIFIC INFECTIOUS DISEASES 

as pneumonia and laryngitis, are always serious, and recovery from 
hemorrhagic smallpox is rare. 

Treatment. — The child should be isolated, and, if possible, promptly 
removed to a smallpox hospital. If seen early in the attack it should 
be vaccinated at once. If the child remains at home, it should pre- 
ferably be isolated on an upper floor, and all communication with the 
rest of the household cut off. Sheets saturated or dampened with a 
solution of carbolic acid should be hung at the doors. All unnecessary 
furniture and all carpets and hangings should be removed from the 
room. There should be separate eating utensils. The nurse in attend- 
ance should wear a gown that completely covers her ordinary dress, 
and should not come in contact with any one save the sick child. 

The treatment is chiefly symptomatic. The violent pain in the 
back of the head is controlled chiefly by the use of sedatives, such as 
morphine sulphate, gr. t X q to y^ every four hours, in the more severe 
cases, and phenacetin, 1 to 3 grains every four hours, or antipyrin, 1 
grain every four hours, in the milder cases. 

The food should be liquid. When there is prostration stimulation 
should be resorted to, and for this purpose 10 to 30 drops of brandy, 
or strychnine sulphate, gr. ¥ ^-g to yj-g-, may be administered every 
three hours. 

If vomiting is persistent, 10 to 20 grains of bismuth subnitrate, 
| of a grain of cerium oxalate, | to 1 dram of iced champagne, or simply 
cracked ice, may be given to check it. 

Quinine sulphate, J to i grain, should be given every four hours 
when the fever runs high, and the temperature may also be reduced 
by sponging. In instances also where delirium is marked, baths 
should be resorted to. These should not be given cool at first; but, 
if a bath with friction at 95° F. does not bring down the fever, the 
temperature of the water may be gradually lowered from 95° to 80° F. 
Plenty of cold water should be given the child to drink, as in fevers of 
other types. 

The treatment of the eruption is important, in order to prevent, if 
possible, the disfigurement which so frequently follows severe attacks 
of smallpox. Various methods have been tried, but none with satis- 
factory results. The application of a cold weak solution of carbolic 
acid or bichloride of mercury upon gauze is in all probability one of the 
most effective methods in use today. During the first seven or eight 
days of the eruption, tincture of iodine, either full or half-strength, 
may be painted once or twice a day over the face or any other portion 
of the body where the eruption is profuse. Many physicians claim 
most excellent results from this treatment. In order to prevent dis- 
semination of the epidermis during the stage of crust formation, it is 
expedient to apply an ointment, such as vaseline or cold cream, freely 
over the skin surface. 

Treatment of the complications requires consideration. In children, 
if diarrhea is severe, opium in the form of paregoric should be admin- 
istered in 10- to 20-drop doses every six hours. Tracheotomy may be 



VACCINIA 713 

necessary if the symptoms point to obstruction of the larynx by edema. 
Great care should be exercised to prevent the occurrence of bed— ore-. 
The eyes should be kept absolutely clean with a solution of boracic 
acid, which will lessen the probability of keratitis. The nose, mouth, 
and throat should also be cleansed frequently to prevent, if possible, 
the formation of hard crusts. In addition, the mouth and nasopharynx 
should be sprayed with a 1 to 5000 solution of potassium permanganate, 
or a 1 to 5 solution of hydrogen peroxide, once or twice a day. 

During the stage of convalescence great care should be exercised 
as to cleanliness and changing the position of the child, to prevent the 
formation of bed-sores or pulmonary complications. There should be 
daily baths followed by inunctions with olive oil. This should be con- 
tinued until the whole skin surface is smooth, and all evidences of 
scab formation have disappeared, since these scabs are potent factors 
in the further dissemination of the disease. 



VACCINIA (COW-POX). 

Vaccinia is an eruptive disease of cattle, communicable to man 
only by inoculation (vaccination), in which event it produces one or 
more lesions, according to the number of points of inoculation. General 
vaccinia, in which the lesions are scattered irregularly all over the 
surface of the body, occurs in about 2 per cent, of all children who are 
vaccinated. The eruption is frequently the result of auto-inoculation 
from the original site of vaccination, and may be erythematous, 
urticarial, scarlatiniform, vesicular, bullous, pustular, or pemphigoid, 
although the most common type is the urticarial. 

It usually appears from the fourth to the tenth day after vaccination, 
but in exceptional cases may occur weeks later. As a rule the eruption 
appears in successive crops, and the lesions are first papular, then 
vesicular, and finally become pustules, thus resembling the original 
sore. The eruption may be seen in all of its different stages of develop- 
ment upon the same individual. 

There may be a variable degree of fever, this depending upon the 
number and extent of the lesions. In the scalatiniform variety there 
is usually great discomfort and a feeling of malaise, as well as moderate 
fever. 

Auto-inoculation is common in children who have affections of the 
skin which cause a break in its continuity. These lesions become 
inoculated with virus from the original sore, and a profuse eruption of 
vaccinia may appear. The lesions may be discrete, but often become 
confluent, and bear some resemblance to the original vaccination mark. 

Vaccinal ophthalmia may also be caused by transmission of the 
virus to the conjunctiva by means of the child's fingers or the indis- 
criminate use of towels, wash rags, and sponges. The crusts dry and 
fall off at the end of the third week, and, as a rule, the lesions of general 
vaccinia entirely disappear after this time, and there are no more new 
crops. Such inoculation confers protection against smallpox. 



714 THE SPECIFIC INFECTIOUS DISEASES 

History. — While Edward Jenner was a medical student at Sodbury, 
he became acquainted with the fact that cowpox protected against 
smallpox. This he learned from a young country girl who, on hearing 
smallpox mentioned, exclaimed "I- cannot take that disease, for I have 
had cow-pox." Jenner mentioned the fact to Hunter, who advised 
him to be inoculated, and thus prove the accuracy of the country 
girl's statement. 

All this occurred in 1780, but it was not until 1796 that Jenner 
inoculated a boy, named James Phipps, eight years of age, with virus 
from the hand of a dairy maid, Sarah Nelmes, who at the time was 
suffering with cow-pox. As early as 1774, Benjamin Jesty, a Yetminster 
farmer, vaccinated his wife and children with matter taken from cows 
that were suffering with cow-pox. Subsequently his children were 
inoculated with matter from the lesions of smallpox, and did not take 
the disease. Nevertheless, the credit must be given to Jenner for 
establishing the fact that cow-pox did protect against smallpox, and 
this truth was established only after much study and experimentation. 
It was not until the year 1800 that cow-pox was introduced into the 
United States by Benjamin Waterhouse, Professor of Physics at 
Harvard, who at that time successfully vaccinated seven of his children. 
Two years later nineteen boys were inoculated, twelve of the number 
being subsequently inoculated with smallpox, and all showed immunity 
to the disease. Two un vaccinated boys were inoculated with the 
same smallpox virus, and both contracted the disease. 

Jenner died on January 6, 1823, and twelve days prior to his death 
he wrote as follows: "My opinion of vaccination is precisely as it 
was when I first promulgated the discovery. It is not in the least 
strengthened by any event that has happened, for it could gain no 
strength. It is not in the least weakened, for, if the failures you speak 
of had not happened, the truth of my assertions respecting those 
coincidences which have occasioned them, would not have been made 
out." 

Vaccine Virus. — Two types of virus exist, the humanized and the 
bovine type. 

Humanized Virus. — Humanized virus is seldom used at present 
because of the possibility of the subject having syphilis, hereditary or 
acquired, or some other constitutional disease. When used it should 
be taken from a vaccine pock of the fifth to the eighth day, and such 
a vesicle should be primary and contain clear fluid. Should there 
exist any inflammatory condition other than that normally present, 
another individual should be sought. Usually the virus is obtained 
from young subjects because of the slighter possibility of their having 
transmissible diseases. 

To obtain the lymph a vesicle is punctured and a capillary tube 
inserted in the puncture. The tube is then sealed, and kept in a cool 
place until needed for use, at which time the ends of the tube are 
broken, and the lymph is expelled by means of a small rubber bulb. 



VACCINIA 715 

Bovine Virus. — Two types of this virus are employed: namely, 
lymph and vesicle pulp. The former is merely the clear lymph from 
a vaccine vesicle, while the latter is a combination of not only the 
lymph, but also the epithelial lining of the pock. This has been 
found to be more active than lymph alone. The lymph may be used 
in a dry form upon points of ivory or celluloid, which are known as 
dry points, or in the form of a glycerinated emulsion which is marketed 
in sealed tubes. The latter form is the one most frequently used. 

Vaccination. — Nowadays the custom of vaccinating children between 
the ages of four and six months has become popular. Should there be 
an epidemic of smallpox, or a history of contact with smallpox, no 
matter what the age of the child may be or whatever else the child 
may be suffering from at the time, it should be immediately vaccinated. 
If there is no smallpox about, the physician ought to decide when the 
child should be vaccinated, and this should be when it is in good 
physical condition. 

Technic of Vaccination. — The part to be vaccinated (preferably the 
left arm in boys and the calf of the leg in girls) should be thoroughly 
disinfected in the following manner: The part should be first washed 
with tincture of green soap and water, and this followed by an applica- 
tion of alcohol, then dried, cleansed with sterile water, and again 
dried with either a clean piece of gauze or a clean towel. The abrasion 
necessary for inoculation of the virus should be made either with a 
lancet or a needle, either of which must have been previously rendered 
sterile by immersion in alcohol. The needle is preferable in view of 
the fact that a new one may be used at each vaccination. Such an 
abrasion, if on the arm, is usually made at the insertion of the deltoid 
muscle, with cross-scarifications about one-third of an inch in length 
and extremely superficial in order to draw only lymph. If blood is 
drawn it has a tendency to prevent absorption, and if the scarifica- 
tions are deep there is a possibility of severe inflammation subsequently. 
The virus should then be expressed upon the abraded area, and care- 
fully rubbed in, which often precludes the possibility of failure. The 
lymph should then be allowed to dry by exposure to the air, after which 
it is covered with a sterile piece of gauze. 

Shields should not be applied, as they have a tendency to produce 
congestion by pressure. To protect the vaccinated area it is advisable 
to keep it covered, either with sterile gauze or by sewing a small piece 
of clean gauze to the sleeve of the undershirt or to the inside of the 
stocking. Should the vesicle be injured, great care must be exercised 
to prevent its infection by other organisms. 

Vaccination may also be performed hypodermically by the use of a 
hypodermic needle. In this method several punctures are made quite 
superficially, and the lymph is injected. 

Stages and Symptoms of Vaccinia. — Practically no symptoms are 
manifest during the first and second days after vaccination. On about 
the fourth day, a redness appears about the site of inoculation which 
increases, then a papule forms, more flat than elevated, which becomes 



716 THE SPECIFIC INFECTIOUS DISEASES 

vesicular on the fifth day, and attains its maximum size by the eighth. 
The vesicle formed is depressed in the centre, elevated at the margins, 
and contains a clear, thin, transparent fluid. On the tenth day an 
extensive areola surrounds the vesicle, the contents of which become 
purulent. At this time there is often marked induration, swelling and 
pain. By the twelfth day the areola begins to lessen, the fluid within 
the vesicle becomes opaque, and shows evidences of drying up. By the 
fifteenth day desiccation is complete, the vesicle dries up, and a hard 
crust is formed which usually falls off at the end of the third or the 
beginning of the fourth week, leaving a pitted red scar which later 
becomes pale. 

Following vaccination there are usually constitutional symptoms 
which may be either mild or marked, according to the degree of 
inoculation. Fever, restlessness, anorexia, and irritability usually 
appear on the third or fourth day, and continue until the tenth or 
twelfth. If the vaccination is on the arm, the axillary glands are 
frequently affected, and become enlarged and tender. If the vaccina- 
tion be on the leg, the inguinal glands may show the same disturbance. 

It is generally conceded that people should be revaccinated every 
seventh year and whenever smallpox is prevalent. 

Not infrequently certain irregularities are met with in vaccination, 
such as complete termination in a week, or the reverse- — namely, a 
very slow development of the pocks. There may be ulceration or 
infection as the result of bruising or scratching, or a number of vesicles 
may appear in the neighborhood of the primary one, or secondary 
vesicles may form in other parts of the body. Vaccination may even 
be fatal in children in whom severe secondary infection takes place. 

The arm may become quite sore, owing to a marked local reaction. 
In these cases moist boric acid dressings should be applied continuously, 
or a 1 per cent, picric acid solution or compound tincture of benzoin 
may be painted on the inflamed areola twice daily. The various other 
complications of vaccinia are, for the most part, surgical, and should 
be treated along these lines. 

Complications. — Ulceration, sloughing, and cellulitis may result 
either from uncleanliness or from injury to the vesicle. Various skin 
disorders, such as erythema, urticaria, erysipelas, and impetigo, also 
glandular abscesses, either axillary or inguinal, may follow vaccination. 
Syphilis may be contracted by the use of humanized virus taken from 
some one suffering with the disease, either hereditary or acquired. 
Such instances are indeed rare, and are of little or no likelihood because 
of, the almost universal use of animal lymph. 

The possibility of transmitting bovine tuberculosis is very slight. 
Tetanus, too, is fortunately rare, because of the extreme precautions 
observed in the preparation of animal lymph; nowadays, if such a 
complication does occur, it is usually due to infection of the vaccine 
pock following an injury. 

It has been thought that vaccination has a certain beneficial influence 
upon the course of some constitutional diseases, particularly syphilis 



TUBERCULOSIS 111 

and tuberculosis. But the reverse is true, in that it has a tendency to 
light up or bring into activity a latent syphilitic or tuberdular taint. 
The general opinion prevails that if vaccination is not successful, 
provided it has been done carefully, it indicates a certain degree of 
immunity to smallpox. 

Value of Vaccination. — In communities in which vaccination is 
systematically practised, smallpox is seldom, if ever, seen. A notable 
illustration of its efficacy is the fact that in Berlin, from 1795 to 1799, 
before vaccination was made compulsory, 65 per cent, of the deaths 
were due to smallpox. Following the introduction of vaccination, the 
figures for the ensuing five years were as follows: 7.5 per cent.; 6.4 
per cent.; 0.7 per cent.; 1.3 per cent.; and 0.2 per cent. The 
mortality from smallpox in persons who have previously been vac- 
cinated ranges from 6 to 8 per cent.; in the unvaccinated it is at 
least 35 per cent., which shows the protective value of a single 
vaccination. 

Contraindications. — In the absence of an epidemic of smallpox, it is 
not advisable to vaccinate an infant until after it is three months old. 
In older children the contraindications to vaccination are general or 
localized skin lesions, either syphilitic or tuberculous, or any other 
severe and recurrent skin disease, whether acute or chronic. Children 
who have just recovered from an exhausting illness, or are debilitated 
by other causes, should not be vaccinated until they regain their 
strength and normal vitality. 

TUBERCULOSIS. 

Tuberculosis is an infectious disease caused by the Bacillus tuber- 
culosis, and characterized by the formation of tubercles or infiltra- 
tions which become caseous or sclerotic, and eventually either 
ulcerate or calcify. It may run an acute, subacute, or chronic course. 

Etiology. — The tubercle bacillus was discovered in 1882, by Robert 
Koch. It is a rod-shaped organism, varying in length from 1.5 to 
3.5 microns, and in breadth from 0.2 to 0.4 micron. The bacilli are 
usually slightly curved, and often beaded, which sometimes causes 
them to be confused with streptococci, though the beads of tubercu- 
losis are merely vacuoles, the result of degeneration. The tubercle 
bacillus is immobile, and of very slow growth when artificially culti- 
vated. It is acid fast, that is, after having been stained by means 
of a dye, it does not become decolorized when treated with an acid, 
but there are other organisms which possess this same peculiarity; 
namely, the Bacillus lepra^ and the smegma group. The tubercle 
bacillus is readily killed when exposed to direct sunlight. 

The culture media used for its growth are blood serum, glycerin 
agar, bouillon, or potato, and to promote their growth on these they 
should be kept at blood heat after being inoculated. The colonies 
appear as grayish-white masses on the surface of the culture media. 
Occasionally the organisms assume a branch-like formation, and may 



718 THE SPECIFIC INFECTIOUS DISEASES 

be seen as minute oval or round bodies which take a deep stain; these 
are known as Schron's capsules. 

In 1901, Koch announced that human and bovine bacilli were 
different, whereas prior to this time he had considered them as one 
and the same, although von Behring and Ravenal had demonstrated 
by experiments that the bacillus of human tuberculosis is capable 
of producing tuberculosis in cattle. The question today seems to 
resolve itself into a probability that the original parentage of the 
organism was one and the same, and that differences in its forms and 
characteristics were produced by its mode of life and its host. The 
disease, so far as is known, can be transmitted from man to cattle 
only when the individual is excreting organisms of the bovine type. 
On the other hand, it is possible for the human organism to become 
infected by the bovine bacillus. 

Parke and Krumweide, in a study of 132 children between the ages 
of 5 and 16 years, found the bovine type in 33 cases which were 
classified as follows: 

Tuberculous cervical adenitis 20 

Abdominal tuberculosis 7 

Generalized tuberculosis 3 

Bone and joint tuberculosis 1 

Tuberculosis of tonsil 1 

Alimentary tuberculosis 1 

In another study of 220 children under five years of age, 59 showed 
the bovine type of the disease, the lesions being distributed as follows. 

Tuberculous cervical adenitis 20 

Abdominal tuberculosis 13 

Generalized tuberculosis 5 

Generalized tuberculosis (of alimentary origin) 10 

Generalized tuberculosis (including meningitis) 2 

Generalized tuberculosis (including meningitis of alimentary origin) . 8 

Tuberculous meningitis 1 

Percentage or Bovine Infections. 

Five to sixteen Under five 

years. years. 

Pulmonary tuberculosis 

Adenitis cervical tuberculosis 37 57 

Abdominal tuberculosis 50 68 

Generalized tuberculosis 40 26 

Meningitis tuberculosis 

Bone and joint tuberculosis 3 

Parke and Krumweide state that the bovine type of tubercle bacillus 
is a menace to the life of the young child, and causes from 6 to 10 
per cent, of the total fatalities from this disease. The bovine infection 
is largely limited to children, but is fatal only in infants and very 
young children, in whom, in a large percentage of cases, it produces 
cervical adenitis and the rarer forms of alimentary tuberculosis. 
The bovine type, as a rule, causes a milder form of tuberculosis than 
the human type. 






TUBERCULOSIS 719 

Distribution. — The bacilli are widely distributed, and are readily 
disseminated by an individual whose secretions contain the organisms. 
They are present in the body in all tubercular lesions save in the 
chronic types of the disease which involve the lymphatic glands and 
the joints. In some instances they are present in the blood, and in 
this manner gain access to various parts of the body. Outside of 
the body they are distributed chiefly by the sputum which has become 
dry and assumed the form of dust, whereby it is readily disseminated 
from place to place. In the tuberculous wards of hospitals, organism 
have been grown from the dust collected, and when inoculated into 
animals have been capable of producing tuberculosis. In the open 
air they are rapidly destroyed, either by direct sunlight or diffused 
daylight. 

The bacillus of bovine tuberculosis is found in the secretions and 
excretions of animals suffering from the disease, in and about their 
stalls, and often in their blood and flesh. The milk of such cattle 
frequently contains the bacilli, whether or not they are suffering with 
tuberculosis of the udder. 

Modes of Infection. — Hereditary Transmission. — The organism may 
be transmitted to the offspring either by the spermatozoa, by the 
ovum, or by the blood through the placenta. Transmission by the 
sperm has not been definitely substantiated; while possible, it seems 
improbable, even though the bacilli have been found in the semen. 
Transmission by the ovum is unquestionably possible, animal experi- 
mentation having confirmed it. Transmission by blood through the 
placenta is, no doubt, the most common method, whether the placenta 
itself be the seat of the disease or not. Transmission by either one 
of the above paths would account for the occurrence of congenital 
tuberculosis. 

On the other hand, the organism may be conveyed to the offspring 
by the parents, and remain latent until such time as the child's powers 
of resistance have become so low as to permit the disease to develop 
rapidly. Nevertheless, it is evident that in both modes of transmission 
the organism in some way gains access to the body. 

The chief factors in favor of hereditary tuberculosis are the follow- 
ing: (1) the comparative frequency with which placental tuberculosis 
has been found; (2) various experiments which tend to show how 
readily the offspring may become infected. The fact^that the parents 
are tuberculous, or the mother tuberculous, does not necessarily mean 
that the offspring will be likewise, for children born of tuberculous 
parents frequently show no evidence of the disease. On the other 
hand, just as many manifest signs of the disease early. 

Other predisposing factors are pathological changes which may 
have occurred within those tissues which are the most frequent site 
of the disease, such as repeated attacks of bronchopneumonia, 
pleurisy, bronchitis, chronic inflammatory conditions which affect 
the mucous membranes of the respiratory tract, and diseased tonsils 
and adenoids. In numerous instances, tuberculosis follows such 



720 THE SPECIFIC INFECTIOUS DISEASES 

contagious diseases as measles, whooping-cough, and influenza, 
though, unquestionably, in such cases the tuberculous infection has 
been latent. 

The organisms may gain access to the body either by the respira- 
tory or the alimentary tract, and children living in homes where 
members of the family are suffering with the disease are apt to con- 
tract it by inhalation; particularly is this so if they are of the age 
when they can creep about the floor, and thus inhale whatever 
particles of dust may be on the surface of the floor. 

The most common cause of tuberculosis in children is contact 
with persons who have pulmonary tuberculosis, which in not a few 
cases is 'transmitted by kissing. Next to its transmission by the 
sputum, tuberculosis is perhaps most often spread through contam- 
inated milk. The clothing, handkerchiefs, carpets, hangings, and 
bedclothing of a patient with tuberculosis may all, for a short time, 
be carriers of the disease. 

When taken into the alimentary tract the bacillus may cause a 
primary tubercular lesion of the intestine, resulting in involvement 
of the mesenteric lymph nodes; or it may penetrate the wall of the 
intestine, and gain access to other parts of the body, causing a gener- 
alized tubercular infection. Again, it has been proven that the 
organism may pass directly through the mucous membrane of the 
respiratory tract without inciting any tubercular lesion of the mem- 
brane itself. The same is true of the intestinal mucosa. 

On the other hand, its passage through such membranes is greatly 
facilitated if, at the time, the membranes are the seat of inflammation, 
whether it be acute or chronic. The bacilli, having lodged on the 
surface of the mucous membrane, are taken up and conveyed by the 
lymphatics to the nearest lymph nodes, where they are either arrested 
or incite some tubercular change within the gland itself; or they may 
pass on through the lymphatics to involve other lymphatic structures. 
The glands so involved become markedly inflamed and swollen, and 
a varying degree of cell proliferation occurs, which eventually results 
in caseation. The bacilli may become encapsulated, and remain 
latent for a varying period of time. Later, through the weakening 
of the individual resistance, or by symbiosis with another germ, they 
may resume their activity and produce the disease. It may be seen, 
therefore, that the resistance, or degree of bodily protective power, 
is an important factor in arresting or promoting the process. 

In younger children the bronchial lymph nodes are most frequently 
involved because of ready access to them by way of the bronchi. 
When affected, they readily undergo caseation and softening, and 
may rupture into one of the smaller bronchi or a bloodvessel, thus 
gaining access to the lungs. On the other hand, autopsies have 
frequently shown the lungs to be affected with little or no involve- 
ment of the bronchial lymph nodes. Consequently, it is not neces- 
sary that they should first be involved in order that the disease may 
extend to the lungs. 



TUBERCULOSIS 



721 



The tubercle, which is the pathological lesion produced by the 
organism, is an inflammatory circumscribed growth, varying in size 
from that of a pinhead, or less, to that of a pea or larger. It is grayish- 
yellow in color, and microscopically is seen to consist of an abundance 
of epithelial cells, in the centre of which are giant cells. The 
organisms themselves may be either intracellular or extracellular. 
The caseation and softening are the direct result of the activity of 
the tubercle bacillus. After the formation of a tubercle, the disease 
may spread by contiguity, in that other tubercles formed nearby 
may fuse and form a single tubercle. 

Again, the infection may be conveyed by the secretions and excre- 
tions of the body, such as the lymphatic stream, which may convey 
infection from one lymph node to another, or, by the urine carrying 
the infection from the kidneys, the primary seat of the disease, to 
the bladder. The organisms may gain access to the blood, either 
directly from the lymph or by rupture of a tubercle into a bloodvessel, 
or by way of the thoracic duct into the venous circulation, thence 
into the arterial circulation. Consequently, in either way the disease 
may be generally distributed throughout the body. In children 
the disease is met with in increasing numbers as they advance in 
years. 

The frequency with which tuberculosis occurs, as shown by 
autopsies, is given by Holt in a table as follows: 



Age of 
Institution. patient. 

New York Infant Asylum Nearly all up to 

2^ years 
Babies' Hospital . . Nearly all under 

3 years 
New York Foundling 

Hospital .... Nearly all under 

3 years 
Miiller (Munich) . . Children of all 

ages 
Hamburger (Vienna) . All ages up to 14 

years 
Hamburger (Vienna) . Including only 

children of 2 

years and less 



Number of 
autopsies. 


Number 

showing 

tuberculosis. 


Percentage 

of cases of 
tuberculosis 


726 


56 


8.0 


1000 


16S ' 


16. S 


1000 


136 


13.6 


500 


200 


40.0 


S4S 


335 


40.0 


497 


120 


24.4 



Lesions. — The lungs are the organs by far most frequently 
affected; next are the bronchial lymph nodes, the spleen, the liver, 
the pleurae, the kidneys, the brain, the intestines, and the mesenteric 
lymph nodes. 

The bronchial lymph nodes and the lungs are the most frequent 
seats of the disease in early infancy, and death as a result of the 
pulmonary process occurs most often during the first two years. In 
many of the remaining cases death is the result of involvement of 
the brain. At this age other forms of tuberculosis are rarely the cause 
of death. This shows that tubercular meningitis is most frequently 
met with in early childhood in conjunction with pulmonary tuber- 
46 



722 THE SPECIFIC INFECTIOUS DISEASES 

culosis. After the third year it more often occurs unaccompanied 
by pulmonary lesions, and is usually secondary to either lymphatic 
or bone tuberculosis. At this time of life, too, the intestines and 
peritoneum are more often affected than in earlier childhood. 

In children under two years of age pulmonary tuberculosis is more 
apt to be diffused throughout the lungs, and it is not until the sixth 
or seventh year that the pulmonary lesions of childhood resemble 
those in adult life. 

Pulmonary Forms. — The younger the child affected, the more 
diffuse is the process in the lungs apt to be. In children who have 
passed the seventh or eighth year, the pathological changes are more 
likely to resemble those found in adults. 

Tuberculous Bronchopneumonia. — This is by far the most common 
form of tuberculosis met with in young children. Its course is usually 
subacute. The lesions consist of caseous areas which, in some 
instances, have undergone softening. Areas of consolidation are 
also present. As a rule both lungs are involved, more frequently 
the upper lobes than the lower. The lung, when sectioned, shows 
the presence of minute nodules of a grayish-yellow color, varying 
in size, and often containing pus, while others which have not under- 
gone softening show microscopically giant cells and tubercle bacilli. 
The nodules are usually surrounded by an area of bronchopneumonia. 
Frequently a cavity is present, varying in size from a walnut to a 
hen's egg. A tendency to encapsulation of the tubercular foci is 
rare, for the softening usually continues until death. 

Miliary Tuberculosis. — Miliary tubercles are present in the lungs 
in practically all cases of pulmonary tuberculosis. They appear 
as minute yellowish-gray tubercles upon the surface, in most instances 
in the neighborhood of an old tuberculous lesion. Except for the 
presence of these minute tubercles, the lung frequently appears to 
be normal, while in other cases the areas between the tubercles are 
congested and the seat of bronchopneumonia. 

These tubercles are usually found within the walls of the smaller 
bronchi, or in the adventitia or intima of the bloodvessels. As a 
result of the presence of tubercle bacilli in these areas, the organisms 
are usually widely scattered throughout the lungs . The bacilli lodge also 
in various organs of the body, and produce a generalized tuberculosis, 
having gained access to the blood either by perforation of the lumen 
of a bloodvessel, or ulceration of a caseous mass which may be extra- 
vascular, or ulceration of a lesion within the bloodvessel wall. Where 
there is lung involvement the pleura usually shows the presence of 
tubercles on its surface. 

Acute Miliary Tuberculosis. — This form of tuberculosis closely 
resembles an acute infectious disease. It may occur at any age, 
is seldom, if ever, primary, and usually follows some focus elsewhere 
in the body, most frequently lesions of the bronchial lymph nodes. 
It may be either active or latent in character, and readily develops 
after the entrance of the organisms into the blood stream, which may 
occur as the result of rupture or ulceration of the diseased lymph 



TUBERCULOSIS 723 

node into a bloodvessel. Tubercles make their appearance through- 
out the body a few days after the organisms have gained access to 
the various organs by way of the blood stream. The serous surfaces, 
as well as the lungs, spleen, and other organs become affected. This 
form of the disease occurs most frequently between the ages of 
twelve and twenty. 

Clinical Varieties. — Three clinical forms of acute tuberculosis are 
usually described: 

1. The general or typhoid form, which gives rise to symptoms 
closely resembling an acute general infection. 

2. The pulmonary form, in which the symptoms are chiefly 
pulmonary. 

3. The meningeal form, in which the symptoms are cerebral and 
spinal. 

1. General or Typhoid Form. — The symptoms in this form are 
similar in many ways to those of typhoid fever, for which it is 
frequently mistaken. The onset is usually gradual, with progressive 
loss in weight, weakness, and the appearance of fever which gradually 
increases in intensity, also an increase in the pulse rate. The lung 
symptoms may be extremely mild. As a rule there is a moderate bron- 
chitis. The absence of nosebleed and of diarrhea, as well as irreg- 
ularity of the temperature and a tendency to cyanosis, should aid in 
distinguishing it from typhoid fever. Excessive sweating, more 
excessive than in typhoid fever, is characteristic. The spleen is 
frequently enlarged, and there have been instances of hemorrhage 
from the bowel. In this form of tuberculosis, involvement of the 
choroid coat is frequent. 

A negative Widal test, together with a negative blood culture, 
will also assist one in making a differential diagnosis, while leuko- 
penia or negative leukocytosis is of no avail in that it is frequently 
observed in uncomplicated miliary tuberculosis. 

Prognosis. — This is, as a rule, unfavorable, the disease terminating 
fatally sooner or later. The duration is usually from one to three 
months, but it may sometimes be but a week or ten days. 

Treatment. — Treatment is usually symptomatic. The fever is 
abated by the use of such drugs as spirits of nitre or antipyrine. Cough 
sedatives are frequently necessary in view of the fact that persistent 
cough is sometimes one of the most annoying symptoms. Needless 
to say, food of the most nourishing character and an abundance of 
fresh air are essential in the treatment. 

2. Pulmonary Form. — In this form the lung symptoms are usually 
severe from the beginning. In children it may follow the infectious 
diseases, such as measles or whooping-cough, and assumes the broncho- 
pneumonic type. In older children there is copious mucopurulent 
expectoration, and there may be hemoptysis. The cough is more or 
less constant, the face usually flushed, and there may be a varying 
degree of cyanosis about the lips and finger-nails. 

Owing to the areas of bronchopneumonia seen in children, the 



724 THE SPECIFIC INFECTIOUS DISEASES 

physical signs differ somewhat from those found in adults. There 
may be areas of hyperresonance or vice versa. Upon auscultation 
at the base of the lungs, the breathing may be of high-pitched, tubular 
character. Rales are heard, either fine and crepitant, or sibilant and 
sonorous. The temperature in this pulmonary form of the disease 
usually rises to 103° or 104° F., the pulse becomes rapid and weak, 
and death may occur within a short period of time, or the disease 
may persist for a year or longer. In some cases the tubercle bacillus 
may be found in the sputum. 

Rapid emaciation, together with persistent cough and fever, ought 
to arouse suspicion of tubercular disease, especially after one of the 
minor contagious diseases. Hemorrhage from the lungs is not uncom- 
mon, and sometimes may be the only suspicious symptom. In the 
bronchopneumonic type a differentiation from either bronchopneu- 
monia or simple bronchitis is often difficult. In the true pneumonic 
form, which rarely affects children, an early diagnosis is practically" 
impossible because of the close resemblance to true pneumonia in 
its earlier stages. Nevertheless, in pneumonia an abatement of fever 
is expected by the tenth or twelfth day and, should it not occur, one 
is led to think of the possibility of pneumonic phthisis. 

Prognosis. — This, unfortunately, is unfavorable, the disease lasting 
usually only a few weeks or months. 

Treatment. — In the acute stage, the treatment is chiefly symptom- 
atic. The subacute and chronic stages are treated the same as chronic 
tuberculosis. 

3. Meningeal Form. — This is more common in children than in 
adults, occurring most frequently between the ages of two and five, 
and is usually secondary to some tuberculous lesion elsewhere, chiefly 
in the bronchial lymphatic glands. Rarely is it primary in the 
meninges, but the meninges about the base of the brain are frequently 
involved. Usually certain prodromal symptoms appear, such as 
progressive loss of weight, irritability, and loss of appetite. Symptoms 
referable to the meninges suddenly make their appearance; there 
are headache, vomiting, fever, and occasionally convulsions. The 
vomiting is characteristic in that it occurs at times other than when 
food is taken. 

The fever rises to 103° or 104° F., the pulse, at first rapid, later 
becomes slow and irregular. Twitching of the muscles is fairly con- 
stant, and the pupils are contracted during the early stage of irritation. 
At this period the symptoms resulting from irritation usually subside, 
but there is marked drowsiness, and at times retraction of the head. 
The pupils become dilated, and the so-called tache cerebrale appears. 
Finally the stage of paralysis sets in, the child becomes markedly 
comatose, and spasmodic contractions of groups of muscles may occur. 
The pulse becomes rapid and feeble, and there are symptoms of the 
so-called typhoid state — namely, delirium, dry coated tongue, and 
incontinence of urine and feces. The duration of the disease varies 
from two days to a month or more. 



TUBERCULOSIS 725 

Diagnosis. — The diagnosis is usually not difficult, especially if 
a previously existing focus can be found elsewhere in the bod}', 
together with the characteristic train of symptoms A lumbar 
puncture may reveal the presence of the bacilli and an abundance 
of small mononuclear lymphocytes, also an increase in the cerebro- 
spinal pressure, which may become as high as 48 to 52 mm. Hg. Of 
course the presence of the tubercle bacillus in the cerebrospinal fluid 
makes the diagnosis positive. 

Meningeal tuberculosis is chiefly to be distinguished from menin- 
gitis due to causes other than the tubercle bacillus. The presence of 
a tuberculous lesion elsewhere in the body is of great aid. Menin- 
gitis resulting from syphilis is usually chronic in form, and rarely 
acute, and is apt to be localized to one side. The presence of tubercles 
in the choroid is diagnostic. 

Prognosis. — This form of the disease is practically always fatal. 
In instances where cures have been reported, there has usually been 
an error in diagnosis. However, recovery has apparently occurred 
in a few cases. 

Treatment. — Though the treatment is limited, every effort should 
be made to combat the symptoms, inasmuch as the disease fre- 
quently proves to be other than tubercular, and a cure may be 
effected. The headache, which is so intense, is often relieved by 
lumbar puncture, and narcotics should be used freely during the stage 
of irritation. Operations upon the skull have so far been of no avail. 

Chronic Tuberculosis. — This form of the disease is usually met 
with after the fourth year. It is contracted either by inhalation or 
by way of the alimentary tract, or is secondary to a previously exist- 
ing tuberculosis, chiefly tuberculosis of the bronchial lymph nodes. 

Symptoms. — The onset is slow, and is accompanied by loss in weight 
and a cough which becomes more or less persistent, together with 
a rise in temperature which often goes unnoticed. In the early stage 
of the disease the pulmonary symptoms are either vague in character 
or absent altogether. Frequently the organisms may be found in 
the sputum prior to any lung manifestation. By auscultation rales 
may often be heard over various parts of the lungs. This is chiefly 
so in younger children, because the disease in them does not neces- 
sarily begin at the apices of the lungs, as it so frequently does in 
adults. Later definite physical signs render a diagnosis possible. 

The chest becomes flattened, there are areas of dulness'on percus- 
sion, and rales, frequently scattered, are heard over the chest. As 
the process continues cavities form, evidences of which are the char- 
acter of the breathing, characteristic metallic rales, and a tympanitic 
note on percussion over the broken-down areas. At this time the 
loss in weight is marked, and the fever becomes irregular. Such a 
child is extremely susceptible to intercurrent infections. 

The diagnosis of the disease in its early stages is extremely impor- 
tant, for upon this alone, in the majority of instances, depends 
the question whether or not a cure can be effected. In all cases in 



726 THE SPECIFIC INFECTIOUS DISEASES 

which there is constant cough with loss in weight and fever of irregu- 
lar type, suspicion should be aroused, and the chest frequently exam- 
ined for signs of the disease, since on these depends the prognosis. 

General Tuberculosis. — In many cases of tuberculosis in infants 
the early signs and symptoms are those of marasmus alone, and tuber- 
culosis is not even suspected until toward the end of the illness. Not 
a few cases of tuberculosis in infants are first recognized at autopsy, 
because of the lack during life of any symptoms or physical signs 
referable to the disease. 

As a rule these infants steadily lose weight and strength, and exhibit 
anemia for which there is no apparent cause. Cough and fever may 
be absent at first, although toward the end of the disease there is, 
as a rule, a daily temperature range of 100° to 102° F., the fever being 
either constant or intermittent. 

Disturbances of the gastro-intestinal tract are the most prominent 
features of the disease, and there is usually indigestion, malassimila- 
tion, vomiting, and diarrhea, although these symptoms are rarely 
due to involvement of the stomach or intestines. Late in the disease 




Fig. 71. — General tuberculosis in a child aged two and a half years. 

a cough develops, the respirations are abnormally rapid, and the 
lungs show evidences of bronchitis which is followed by bronchopneu- 
monia. 

The terminal symptoms are dyspnea, cyanosis, marked asthenia, 
emaciation, and prostration, death resulting either from the pulmonary 
lesion, menigeal involvement, or general exhaustion. 

Tuberculosis of the Glands. — Lymphatic Glands, Bronchial.— The 
glands most frequently affected in early infancy are the bronchial 
lymph nodes, comprising those about the trachea and its bifurcation, 
and those which accompany the bronchi into the lungs. Usually 
they are all affected at the same time. The changes which occur 
within the glands are identical with the changes elsewhere resulting 
from the presence of the organism. At times they may undergo 
suppuration, but not as frequently as do the cervical lymphatics 
when involved. 

Suppuration of the bronchial glands is most common during infancy, 
but calcification of these glands rarely occurs at this age. When 
suppuration takes place, the escape of pus may cause a mediastinal 
or retropharyngeal abscess. 



TUBERCULOSIS 727 

Other sequelae of suppurative tuberculous bronchial lymphadenitis 
are compression and ulceration of the trachea and esophagus, acute 
miliary tuberculosis, and hemorrhage from the erosion of a large blood- 
vessel. When the glands which have undergone caseation become 
encapsulated, few of these dire mishaps occur, and the infection may 
be locked up in the glands for years, producing no symptoms, and 
doing no apparent harm. 

Cervical Glands. — In 90 per cent, of all cases of tuberculous lymphad- 
enitis the cervical glands are involved, and less frequently the other 
superficial lymph nodes of the body. Caseation of the external lym- 
phatics in the neck, groin, axilla, and other regions of the body is usually 
followed by ulceration, and the discharge of pus externally. 

Mesenteric Glands.— The same pathological changes occur in these 
glands as in other lymphatic glands. Softening may occur and, from 
leakage or rupture, produce a localized peritonitis. Enlargement of 
this group of glands may give rise to symptoms which are the result 
of pressure upon the vena cava, the portal vein, or thoracic duct. 
About 60 per cent, of all tuberculous cases in children show invasion 
of the mesenteric glands. They are rarely involved independently 
of the bronchial lymph nodes, and only occasionally is the condition 
sufficiently developed to be recognized independently of tuberculous 
peritonitis. 

Symptoms. — The symptoms of abdominal tuberculosis are disten- 
tion and pain in the abdomen, intestinal indigestion, flatulence, 
diarrhea, persistent elevation of temperature, and slow but progres- 
sive emaciation. Upon abdominal examination the glands may some- 
times be palpated, if relaxation of the abdominal walls can be secured. 
Masses may be felt in both iliac fossie, and quite a prominent group 
palpated in the region of the appendix, which forms a tumor. 

Inasmuch as the symptoms somewhat fesemble those of chronic 
appendicitis, a rectal examination may be necessary to determine 
whether or not there is enlargement of the appendix. The outlook 
in the cases which are sufficiently developed to be diagnosed is, as 
a rule, unfavorable. Recovery may take place, however, with surpris- 
ing frequency, so that hope should never be abandoned. Still recom- 
mends laparotomy, with removal of the infected glands and the 
breaking up of adhesions, in addition to the routine treatment for 
all forms of tuberculosis. 

Pleura. — Rarely does the pleura escape in tuberculosis of the lungs. 
In* the generalized form of the disease it may be the seat of numerous 
miliary tubercles. Thickening of the pleura, together with adhesions 
over a portion of the lung involved, is quite frequent. Serous effusions 
which are often sacculated are not uncommon in infants and young 
children; empyema may occur, but is rare. The fibrous adhesions 
which form in tuberculous pleurisy may cause marked interference 
with pulmonary expansion. 

Heart. — The pericardium is rarely affected save in acute general 
miliary tuberculosis, when the visceral surface may be dotted with a 



728 



THE SPECIFIC INFECTIOUS DISEASES 



few scattered tubercles. Tuberculous lesions of the endocardium 
and myocardium are practically unknown. 

Brain. — In very early infancy and prior to the third year the brain 
is not uncommonly affected, but after this it is less frequently attacked. 
Minute miliary tubercles or caseous nodules may be present. About 

70 per cent, of the cases of tuberculous 
meningitis are seen between the ages 
of one and five years. 

Liver. — This organ usually becomes 
affected in general tuberculosis, num- 
erous miliary tubercles forming on its 
surface and throughout its interior. 
Spleen. — When involved, practically 
the same changes are found here as 
within the liver — namely, miliary 
tubercles on its surface and throughout 
its interior. It is rarely enlarged save 
in instances where nodules have formed. 
Intestines. — In infancy involvement 
of the intestines is less common than 
in later childhood, but usually the 
small intestine is the seat of the dis- 
ease. Minute nodules are deposited 
on the surface of the bowel. Ulcers 
are frequently found, especially in the 
neighborhood of Peyer's patches, usu- 
ally extending only into the mucosa, 
but, if of long duration, they may 
involve other coats of the bowel. As 
a result of this ulceration perforation 
or cicatrization may take place and 
cause a narrowing of the lumen of the 
intestine. 

Peritoneum. — Rarely is the perito- 
neum affected in early childhood, but 
in general tuberculosis of older children 
it may be the seat of miliary tubercles 
or tuberculous nodules. 
Kidney. — Miliary tubercles or nodules may be found in the kidneys 
accompanying generalized tuberculosis, although rarely. Tubercu- 
losis elsewhere in the genito-urinary tract is most uncommon, although 
several cases of involvement of the testicle have been reported. 

Prognosis.— The prognosis in tuberculosis of children depends 
to a great extent upon the location of the disease. Pulmonary lesions 
are always serious, and well developed foci usually prove fatal. Gland- 
ular tuberculosis is in many instances followed by recovery. The 
environment, climate, care, and treatment of a child with tubercu- 
lous lesions anywhere in the body also influence the prognosis to 
a great extent. 




Fig. 72. — Tuberculous perito- 
nitis, tuberculous spondylitis, and 
tuberculous glands of the neck in a 
boy, aged seven years. 



TUBERCULOSIS 720 

Prophylaxis. — The prevention of tuberculosis is a most important, 
and at the same time a very difficult problem, especially among 
the poor. It can he accomplished, however, if tubercle bacilli from 
every source are destroyed and needless exposure is avoided. Sputum 
from tuberculous patient- should be carefully collected and destroyed, 
since this is probably the most frequent source of tuberculous infec- 
tion. The living quarters of tuberculous patients should be disin- 
fected before children or any other persons are allowed to enter them. 
A tuberculous mother should neither nurse her child nor kis> it upon 
the mouth, and the less she fondles it the better. No child should 
be allowed to associate in any way with tuberculous persons, for it 
has been demonstrated that tuberculous spray is projected several 
feet when a consumptive coughs. 

Systematic school inspection is a great aid in differentiating tuber- 
culous children from healthy ones. If the parents are tuberculous 
the utmost precautions are necessary in the home to prevent infection. 
The milk supply is an important consideration, and. if not obtained 
from a herd that has been tested with tuberculin, the milk should 
be pasteurized before giving it to children. 

Since delicate children and those with chronic catarrh of the upper 
respiratory tract are especially liable to tuberculosis, they should 
be carefully protected from exposure and should lead an outdoor 
life, preferably in the country, fresh air and sunshine being the two 
great preventives^ of this di-ease. These precautions are especially 
applicable to children whose parents are tuberculous. 

Tuberculin Tests. — In view of recent claims of benefit to be attrib- 
uted to the u>e of old tuberculin as an aid to diagnosis, it seems 
expedient to give it brief mention. The preparation itself is a fluid, 
brownish in color, consisting of the filtrate from a culture of tubercle 
bacilli in glycerin bouillon after the bacilli have been filtered off. 
In short, it consists chiefly of the products of the bacillus. When 
used, it is diluted with water and injected subcutaneously. with all 
necessary asceptic precautions. The amount to be used is deter- 
mined by the condition of the patient, and where there are evidences 
of tuberculous involvement should be extremely small. 

The reaction following its injection manifests itself generally by 
a slow rise in temperature, for six to eight hours after the injection, 
followed by a rapid rise during the next few hours, and then a gradual 
decline. During the rise in temperature there may be such symptoms 
as headache, vomiting, and the like. A rise in rectal temperature to 
99i° F. is considered positive. 

It also produces a reaction in the tissues affected by the disease. 
causing them to become congested, and to evince changes reactionary 
in type. Lastly there is a reaction about the site of the injec- 
tion, chiefly a hyperemia, which makes its appearance six to eight 
hours after the injection, and may last from a few to several days. 
Tuberculin is used cutaneously, subcutaneously. and in the eye in 
order to detect earlv. latent, or doubtful cases of tuberculosis. The 



730 THE SPECIFIC INFECTIOUS DISEASES 

cutaneous test is, perhaps, the one most extensively employed, and 
the eye test least of all. In children these methods of determining 
tuberculosis are especially valuable. 

Cutaneous. — The cutaneous test, or von Pirquet reaction, is prac- 
tically a vaccination with tuberculin. The forearm is the site chosen, 
and after carefully washing the skin with alcohol or ether a small 
superficial scarification is made, preferably with a special scarifier, 
and a drop of undiluted tuberculin is then applied. It has been our 
practise to make two such vaccinations, and then to scarify an area 
between them to which no tuberculin is applied, this untreated area 
being used as a control. 

The arm should then be held by the parent, or nurse, until the 
scarified areas are quite dry, so that there will be no contamination. 
In some instances the arm may be dressed with a piece of sterile 
gauze. 

In active cases the reaction is noticeable within twenty-four hours, 
and consists of a red areola around the points of inoculation. A small 
red papule also forms, but disappears in the course of a few days or 
a week, the size of the inflammatory areola being an indication of 
the degree of the reaction. 

The untreated scarification should heal with no sign of inflam- 
mation. The inflammatory areolas usually begin to fade the second 
or third day, but marked reactions may be visible for as long as ten 
days. Infiltration of the skin, and even induration, is sometimes 
observed, and in rare cases vesiculation. 

This test is very valuable in infants and children under two years 
of age, and a positive reaction may be regarded as significant of 
tuberculosis in every case. A negative reaction indicates the absence 
of any tuberculous focus. These findings are invariably supported 
by physical examination and laboratory and autopsy findings, but 
no test for tuberculosis is as conclusive as is the detection of the 
tubercle bacillus in the cerebrospinal fluid, sputum, or elsewhere. 

The reaction fails to appear in the eruptive stage of measles, and 
is very unreliable in cachectic conditions, scarlet fever, diphtheria, 
and typhoid fever. A second test is advisable when the first test 
is negative. 

Subcutaneous. — The subcutaneous test, or stick reaction of Ham- 
burger, consists in the injection of t ^-q to toVo °f a milligram 
of tuberculin beneath the skin of the forearm. Two reactions are 
observed, one at the point where the needle penetrates the skin, and 
a larger area where the tuberculin is injected. The reaction, which 
comprises swelling, redness, and induration, may appear in 24 hours, 
and last for five or six days. 

Moro Test. — The Moro test consists in applying 1 grain of an 
ointment made of equal parts of old tuberculin and anhydrous lano- 
line to the epigastric or submammary region. The finger used for 
this inunction should be protected by a rubber cot, and the salve 
spread only over an area two inches in diameter, which has previously 



TUBERCULOSIS 731 

been carefully cleansed. A control may be made by rubbing plain 
lanoline upon an area adjacent to the inoculated skin. 

The reaction consists in a papular or vesicular eruption which 
appears in twelve to forty-eight hours, and persists for several days. 
In severe cases it is followed by pigmentation. 

Eye Reaction. — The ophthalmic reaction, or Calmette test, is per- 
formed by dropping in the eye 0.5 per cent, solution of precipitated 
tuberculin in sterile salt solution. Within six to twelve hours there 
is swelling, redness, and injection of the palpebral conjunctiva with 
a slight or copious mucofibrinous secretion. The instillation should 
be done at night so that the reaction may be observed the following day. 

The inflammation in the eye subsides in from one to three days, 
but only healthy eyes should be injected, and any sign of tuberculosis 
about the eye is a special contra-indication. The child's hands must 
be kept away from the eyes as long as they are inflamed. In older 
children, and in out-patient practice, this test is not recommended; 
and, as injury to the eye has occasionally occurred, the ophthalmic 
test is now very little employed. 

Numerous modifications have been advanced since the von Pirquet 
reaction came into use, such as the application of ointment containing 
tuberculin, this being known as the salve reaction. None of these, 
however, has proven as positive and conclusive in its reaction as 
the von Pirquet. 

The following statistics are given by Holt to show the relation of 
age to tuberculin tests in the child: 







Number of 


Per cent. 


of 


Number of 


Per cent, of 


Age. 




cases. 


tuberculosis. 


tests. 


reactions. 


Under 3 


months 


. . 105 


4 




147 





3 to 6 


« 


. . 73 


18 




64 


5 


6 to 12 


<< 


. . 140 


23 




67 


16 


2 


years 


. . 179 


40 




ss 


24 


3 to 4 


" 


. . 175 


60 




127 


37 


5 to 6 


" 


. . 67 


56 




101 


53 


7 to 10 


" 


. . 65 


63 




182 


57 


11 to 14 


" 


. . 44 


70 




100 


68 


Over 14 


" 








112 


90 



848 40 988 41 

Treatment. — Of chief importance in the treatment of the disease 
are the hygienic and dietetic measures. Such a child should be kept 
out of doors as much as possible. It is frequently necessary to try 
a change of climate, such as sea air in the very early stages, and higher 
altitudes later. Foods of the most nourishing type, highly abundant 
in fats, are to be recommended. ZNIilk is the best staple of the diet, and 
cream is almost as beneficial as cod-liver oil, if digested and assimi- 
lated in sufficient quantities. All alcoholic stimulants should be 
avoided, unless absolutely necessary. An abundance of sleep and 
rest is important, and moderate exercise should be taken. The admin- 
istration of drugs should be delayed until it becomes absolutely neces- 
sary, and then they should be used cautiously in order to prevent any 
irritation of the stomach. 



732 THE SPECIFIC INFECTIOUS DISEASES 

Tuberculin is recommended by some clinicians. It should be 
carefully used, beginning with extremely small doses, such as 5-^ 
of a mg., and these increased when there is no reaction. 

Other symptoms which necessitate consideration are the night- 
sweats which so frequently cause extreme weakness. The use of 
diluted vinegar, applied to the surface of the body in the form of 
a sponge bath, is frequently followed by relief. The fever should be 
combated as is best possible. Antipyretics, such as antipyrin, are 
sometimes of value. Hemoptysis is best treated by rest in bed and 
the use of morphin, either hypodermically or by mouth, in doses 
of 4V to yq- of a grain. 

Cod-liver oil, if tolerated by the stomach, is very valuable for 
the upbuilding of the child's general health, and may be given in 
I to 1 dram doses, three or four times daily. It gives the best results 
when taken after meals. The syrup of the iodide of iron is especially 
beneficial in glandular tuberculosis, given in 5- to 20-drop doses after 
meals. 

In tuberculous adentitis, iodine may be used locally in the form of 
a 5 to 10 per cent, ointment, with lanoline as a base. A 10 per cent, 
guaiacol ointment is also valuable in some cases, and in children the 
local use of this drug is followed by better results than its internal 
administration. Fowler's solution is a good tonic, given in 1- to 
3-drop doses three times a day combined with the syrup of hypo- 
phosphites or elixir of glycerophosphates. 

Cresote may be given in 1- to 2-minim doses, in pill, in an emul- 
sion with cod-liver oil, or by inhalation. Inunctions of cod-liver 
and other nutritive oils are advisable when internal medication is 
contraindicated by intolerance of the gastro-intestinal tract. 



MALARIA. 

Malaria is an infectious disease, due to a specific organism known 
as the Plasmodium malarise, and characterized by fever either of 
intermittent or remittent type, or by poisoning of a chronic type 
which results in anemia and splenic enlargement. 

Etiology. — The parasite was discovered, in 1880, by Laveran, and in 
1897 the mode of transmission was demonstrated by Ross. The 
Plasmodium is distinctly a blood parasite, which gains access to the 
blood stream through the sting of mosquitoes, particularly the female 
Anopheles. 

Malaria is common in infants and young children in regions where 
the disease is prevalent - , and may occur in utero. One attack confers 
no immunity from future attacks. 

Distribution.— The disease is diminishing everywhere, being now 
chiefly seen in southern Russia and Italy. It is quite prevalent in 
India, also in Africa, where it is of extremely pernicious type. In the 
United States it is steadily disappearing, though it still prevails in some 



MALARIA 733 

sections of the South, and during the spring and autumn months is 
very prevalent in the tropics. 

The Parasite. — The parasite gains access to the stomach of the 
mosquito through the blood stream and forms minute cysts, the 
contents of which become transformed into crescent-shaped germs 
which, after the eruption of the cysts, pass to the salivary gland- of 
the mosquito, and are readily transmitted to the human being by the 
bite of the mosquito. These young parasites enter into the human 
blood corpuscles, and there undergo a cycle of development. 

There are two groups of organisms: (1) the large parasite, con- 
sisting of two types — the tertian and quartan organisms; (2) the small 
parasite of tropical fevers, known as the estivo-autumnal parasite. 

Large Parasites. — The tertian is by far the most common of the large 
parasites, and passes through its cycle within forty-eight hours, giving 
rise to paroxysms on alternate days, provided there be but a single 
infection. Such paroxysms occur during segmentation, and last from 
twelve to fourteen hours. Should there be a double infection, a 
paroxysm occurs daily (quotidian fever), and upon examination of 
the blood two distinct groups of organisms will be found. In rare 
cases there may be more than two infections. 

The parasite is non-pigmented and egg-shaped. Sometimes a 
small swelling is perceptible along half of the ring, giving it the appear- 
ance of a signet ring. It possesses in marked degree the power of 
ameboid movement, and thus undergoes frequent changes of shape 
and position. Occasionally the parasite undergoes another form of 
development, with ameboid processes different from the rings. The 
small tertian rings enlarge within twenty-four hours, obtaining their 
pigment granules from the hemoglobin of the corpuscles, which become 
much enlarged and fade. Within another twelve hours the parasites 
are converted into disks, bluish in color which, prior to the paroxysm, 
divide into minute egg-shaped bodies which are the young parasites. 
During this latter cycle the corpuscle becomes progressively paler, 
and finally loses its outline completely. Each segment separates 
individually as a hyaline organism, and gains access to other corpuscles. 

Other forms of the tertian parasite are the extracellular varieties, 
which consist of two types, the gametocytes and the degeneration 
forms. The latter are merely those types which have escaped from 
their cells and have died. The gametocytes correspond to the crescents 
of the estivo-autumnal form, and occur after there have been frequent 
attacks of fever, appearing in the blood as extremely large organisms. 
Often they are double the size of a red corpuscle, and contain pig- 
ment which is more or less diffusely scattered. They never show 
segmentative changes, but are extremely active, and intended for 
sexual development. 

Quartan Parasites. — This form differs from the tertian variety in 
that it requires seventy-two hours for its cycle of development instead 
of forty-eight hours, thus causing the paroxysms to occur on the fourth 
day. Should two groups be present, there will be paroxysms on two 



734 THE SPECIFIC INFECTIOUS DISEASES 

succeeding days, followed by a day of rest. If three groups are 
present, the fever will be quotidian. In the early stages the parasite 
cannot be differentiated from the tertian variety, but upon the appear- 
ance of the pigment it is found to be coarser in type, and is capable of 
less activity. 

Coincident with the growth of the parasite the corpuscle shrinks and 
becomes small, and its margin becomes irregular in outline. The 
parasitic protoplasm has a waxy appearance, consequently is more 
refractive than the tertian varieties. At the end of twenty-four 
hours the blood cell becomes crenated, brassy in color, and the pig- 
ment loses its activity. At the end of sixty hours the outline of the 
cell is completely lost, the organism is motionless, and pigment collects 
about the periphery. 

Later the pigment migrates toward the centre, eventually collecting 
there, and segmentation begins, eight to twelve young parasites being 
formed. Here also 'gametes and spheres may be seen, but diifer from 
those of the tertian type by their smaller size. 

Estivo-autumnal Parasites.— This form, met with in the tropics, is 
the most dangerous of the three types of plasmodia. Early in the 
infection the grouping is distinct, but they soon separate, and at 
different stages of development are later found in the internal organs. 
The course and duration of the cycle is not always the same, therefore 
the fever is more or less continuous, loses its intermittency, and 
sometimes closely resembles the fever of typhoid. 

In the very early stages, the development of hyaline forms differs 
but little from that of the tertian and quartan types. They are 
very refractive, and can be readily seen. The pigment within the 
bodies is of fine type. The blood cell is markedly enlarged by the 
parasite, frequently becoming crenated, and is brassy in appearance 
during the very early stages of development, but gradually ceases to 
exist in the peripheral circulation, and remains chiefly within the 
spleen. At times, the plasmodium may be found within the 
peripheral blood stream, in all stages of its development. Segmen- 
tation occurs precisely the same as in the tertian variety. Crescents 
later make their appearance within the blood corpuscles, become 
spindle-shaped, and eventually turn into spheres. 

Lesions. — The lesions in children affected with malaria are practically 
the same as those in the adult. Chief among them are destruction 
of the red corpuscles and enlargement of the spleen which, in the 
chronic type, becomes hyperplastic and pigmented. Other organs, 
such as the liver, kidneys, and brain, may show evidences of pig- 
mentation, depending upon the duration of the infection. 

Clinical Forms of Malaria. — Intermittent Forms. — Two varieties of 
this type are seen — namely, the tertian and the quartan, the latter 
being the more common. Both are characterized by a cold and hot 
stage. The former begins with headache, lassitude, and sometimes by 
nausea and vomiting, which are soon followed by a chill. This may 
be so severe as to cause chattering of the teeth, shaking of the body, 



MALARIA 735 

and a cold, bluish appearance of the skin. The pulse becomes rapid, 
and there may be an increased quantity of urine voided. At this time 
the skin surface may be subnormal in temperature, whereas the 
temperature by rectum or axilla is very much elevated. 

This stage may last from a few minutes to a couple of hours, and then 
the hot stage sets in. The skin temperature becomes elevated, the face 
is flushed, the pulse full and bounding. This lasts from one to several 
hours, and is followed by the sweating stage, during which perspiration 
appears all over the skin surface, and results in a profuse sweat. 
Coincident with this the headache, nausea, and other symptoms 
disappear, and the patient, overcome by exhaustion, sinks into sleep. 

Marked variations in the course of the disease may be observed in 
very young children, the different stages being indistinct, and the 
disease assuming a remittent character. In very young children cyan- 
osis takes the place of chills; there is restlessness, yawning, nausea, 
twitching or convulsions, coldness of the extremities, and sometimes 
diarrhea. The hot stage is almost invariably accompanied by fever 
of a higher degree than is seen in adults, often reaching 10.")° to 106° F. 

The child is restless also in this stage; the face is hot and flushed, 
the eyes are injected; there is severe pain in the head, back, and 
limbs, the pulse is full and rapid, and the urine scanty and high- 
colored. This stage usually lasts an hour or two, after which the 
pain and fever subside, and the child breaks into a profuse sweat. 

The child six years old or more has paroxysms similar to those in the 
adult, but very often the symptoms in younger children are so masked 
that malaria is not suspected at first, and a diagnosis of progressive 
anemia may be made because of the pallor and enlarged spleen. In 
the tertian form of malaria, the child may appear perfectly well in the 
interval between paroxysms. 

The sweating stage is often entirely wanting, or may be so slight 
as to be unnoticed. The disease may make its appearance as a remittent 
fever, and eventually becomes intermittent. The quotidian type is 
the form most frequently observed in children. Next in frequency 
is the tertian variety, whereas the quartan form is extremely rare. 
Examination of the spleen usually shows some degree of enlargement, 
and in chronic cases the liver may be enlarged. 

The course of the disease varies greatly. Recovery may occur 
after a few paroxysms with little or no medication. When malaria 
persists for some length of time, anemia and hematogenous jaundice 
may result from blood destruction, or the disease may eventually 
become chronic. 

Irregular Form. — In young children the disease is apt to manifest 
itself by merely vague symptoms, instead of the train of symptoms 
which usually mark the onset in adults. Nervous phenomena are 
common, such as severe frontal headache accompanied by vomiting 
and lassitude. Pain in any part of the body, together with some 
tenderness, may be the first sign of a paroxysm. Again, a paroxysm 
may be ushered in with vomiting, high fever, embarrassed respiration, 



736 THE SPECIFIC INFECTIOUS DISEASES 

cyanosis, and prostration. Frequently moist rales may be heard over 
the lungs, and cause the disease to be mistaken for pneumonia. 

Chronic Forms. — In many instances these forms can be recognized 
only by finding the malarial parasites in the blood. Anemia, with 
fever and enlargement of the spleen, is the most constant symptom. 
The anemia is usually quite pronounced, the spleen in most instances 
sufficiently enlarged to be readily palpated, while the fever is often 
so mild that it is entirely unnoticed. Other symptoms of minor 
importance which may manifest themselves are headache, occasional 
vomiting, weakness, constipation, muscular pains, and mild bronchitis. 

When a child has suffered from repeated attacks of malaria, or the 
disease becomes chronic, marked cachexia may develop. The child 
becomes emaciated, there are gastro-intestinal disturbances with 
anorexia and diarrhea, the features are drawn and pinched. 

Pernicious Malaria. — Pernicious malaria is rarely seen in temperate 
climates; it is characterized by extreme intensification of all the 
symptoms. 

Diagnosis. — This can readily be made on finding the parasites in the 
blood, especially if the blood is examined at the time of a paroxysm, 
and quinin has not been administered. Often the blood if taken from 
the fingers will be negative, consequently, whenever possible, it should 
be removed from the spleen. In view of the fact that conditions are 
not always favorable for making a blood examination, either because 
of lack of experience or equipment, the therapeutic test should be 
resorted to, namely, the administration of quinin. 

Suspicion should always be aroused if, in a given case, the symptoms 
are more or less periodic in nature and the spleen is enlarged. In the 
chronic forms of the disease the profound anemia and cachexia, 
together with muscular pains, fever of low-grade type, and splenic 
enlargement ought to differentiate the disease from tuberculosis, 
peritonitis, meningitis, lymphangitis, also from empyema, endo- 
carditis, typhoid fever, and influenza. Because of the fever and" 
recurrent chills which accompany pyelitis this disease is frequently 
confounded with malaria. Certain affections accompanied by enlarge- 
ment of the spleen, such as leukemia, rickets, and hereditary syphilis, 
must also be differentiated. These diseases can usually be excluded by 
careful examination, and the diagnosis of malaria confirmed by the 
therapeutic test, administration of quinine, and by examination of the 
blood. 

Prognosis. — As a rule, the prognosis is favorable if the child affected 
by the disease does not reside in a malarial district. In a very young 
child, a severe attack of malaria may so lower its power of resistance 
as to make it particularly susceptible to infections of other types. 
As a rule mild cases eventuate in spontaneous recovery, and in the 
majority of cases of malaria children recover promptly if the disease 
is correctly diagnosed and treated. 

Treatment. — Prophylaxis. — In view of our knowledge of the mode 
of transmission of the disease, not only can its prevention be accom- 



MALARIA 737 

plished, but the disease can as well be ultimately exterminated. All 
houses in malarial districts should be screened by mosquito nets, and 
all parts of the body exposed to the bite of the mosquito should be 
bathed with lotions, which contain such drugs as menthol, turpentine, 
or pennyroyal, which are obnoxious to the mosquito. Pools of water 
should be drained, and when this is impossible petroleum should be 
sprayed on the surface. Children who have previously suffered from 
the disease should undergo treatment each spring and autumn for at 
least four or five years following an initial attack. 

Prophylaxis is most important, especially in malarious districts. 
The child's sleeping quarters should be effectively screened, and it 
should be protected from mosquitoes in every possible way. 

The treatment of the disease is more or less symptomatic; in the 
cold stage stimulation, and in the hot stage the application of cold to 
the body in the form of sponging, or an ice-bag to the head. Laxatives 
should be freely given early in the attack. 

Administration of Quinine. — Owing to the disagreeable taste of this 
drug it is necessary to administer it in such forms as are willingly taken, 
and will cause the least irritation to the stomach. The bisulphate 
of quinine seems to have preference over other forms in that it is less 
likely to upset the stomach. When given by mouth an aqueous solu- 
tion suffices, a fluidram containing 1 or 2 grains of the drug being 
administered four times daily, the last dose three or four hours before 
the expected paroxysm. Older children may be given 3 to 5 grains in 
the same manner. The administration of larger doses of quinine, that 
is, 2 grains every two hours, is often of advantage, if given for eight 
hours preceding the paroxysm, and 1 to 2 grains three times a day in 
the intervals between attacks. Massive doses may be gradually 
decreased as the symptoms subside. 

When quinine is given by rectum a larger dose is necessary, and it 
should be injected in a starchy solution of some kind, such as gruel. 
It may be administered hypodermically in the form of the bimuriate 
with urea, bisulphate or hydrobromate, and the hydrochlorosulphate. 
Because of its irritating properties it seldom if ever should be used 
in this manner, as it almost invariably causes a marked induration at 
the site of injection, and necrosis of the tissues may result. Especially 
is this apt to be the case when it is administered in the above manner 
to very young children or to those whose resistance is lowered. 

In older children the disagreeable taste of quinine can to a certain 
extent be disguised by the use of such vehicles as syrup of sarsaparilla, 
syrup of orange, etc., or it may be given in chocolate-coated quinine 
lozenges. Euquinine is easier to administer to young children because 
practically tasteless. The dose is the same as that of quinine sulphate. 
In still older children quinine may be administered in the same way as 
to adults. 

In order to obtain the maximum results, quinine should be so admin- 
istered that a relatively large dose is taken a few hours prior to the time 
of the expected paroxysm. This, however, is not always possible if 
47 



738 THE SPECIFIC INFECTIOUS DISEASES 

the stomach shows intolerance of the drug. Children will often be 
found to take relatively large quantities of quinine, 8 to 10 grains of the 
sulphate, and 10 to 12 grains of the bisulphate daily, without any 
evidence of disturbance. Under intelligent treatment with quinine, the 
spleen will diminish in size, and the paroxysms disappear. 

Children, as stated, usually bear quinine well, and cinchonism does 
not occur as readily as in adults. Even after the child has apparently 
recovered, it is a good prophylactic measure to give 10 to 15 grains 
of quinine sulphate one day out of each week until the anemia has 
disappeared and the spleen is no longer palpable. It should then 
be given periodically at longer intervals. In the chronic forms of 
malaria, Fowler's solution and ferric chloride, each 1 to 3 drops, 
should be given in combination with quinine, and the children, when 
possible, removed to a different climate. 

SYPHILIS. 

Syphilis is a communicable disease which results from infection by a 
specific microorganism known as the Spirochseta pallida of Schaudinn. 
The organism is found in the primary lesion and the inguinal lymphatic 
glands, also in the liver, spleen, and cutaneous lesions of congenital 
syphilis. 

In the acquired form syphilis is characterized by the appearance of a 
chancre followed by general lymphatic involvement, by eruption on 
the skin and the mucous membranes, then by infiltration of the body 
tissues, the bones, and their covering, eventually by the formation 
of gummata, which appear chiefly in the connective tissue. Both 
the acquired and hereditary forms of the disease are seen in infancy 
and childhood. 

Acquired Syphilis. — This form of the disease is occasionally seen 
in children, though less commonly than the hereditary form. 

Modes of Infection. — Infection occurs in various ways, being chiefly 
transmitted by the mother, who acquires syphilis after the child's 
birth, and conveys it to the offspring either by nursing, kissing, or 
other form of contact. It is possible for a child to become infected 
at the time of its birth, but this is rare, and is due to syphilitic lesions 
upon the genitalia of the mother. Infection may also be conveyed 
by wet nurses or by lesions upon the nipple. 

The statistics of Fournier, showing the source of infection in a series 
of 40 cases, attributed the infection to parents in 19, to nurses in 8, 
to servants in 4, to sexual contact in 4, to vaccination in 2, to other 
children in 2, and to the physician in 1. 

Symptoms. — The disease follows the same course in children as in 
adults. In from three weeks to a month after inoculation, the primary 
lesion, or chancre, appears at the site of infection, which is usually 
about the mouth or some other part of the face, rarely the genitals. 
This is followed by the appearance of secondary symptoms, chief of 
which are eruptions upon the skin and mucous membranes, later by 



SYPHILIS 739 

tertiary symptoms which may appear at any time from three to 
twenty-five years after the infection. 

Prognosis. — The prognosis in acquired syphilis is much more favor- 
able than in the hereditary form, and the course of the disease is 
usually mild. Even in infancy, there is no marked impairment of the 
general health, and the mortality is less than 10 per cent, of that in 
hereditary syphilis. 

Diagnosis. — In the acquired form the diagnosis is made by the 
appearance of a chancre, by a history of infection, and by secondary 
manifestations. In hereditary syphilis there is no primary lesion. The 
infant has chronic rhinitis, and pemphigus or bulla? on the palms and 
soles which are not observed in the acquired form. Hutchinson's 
teeth are strongly suggestive of congenital syphilis. 

Hereditary Syphilis. — This form of the disease is transmitted either 
from the father or from the mother or from both parents. Transmission 
depends to some extent upon the stage of the disease in the parents 
at the time of conception, and is more apt to occur during the secondary 
stage. In cases where the parents have been infected prior to the birth 
of any of their children, the first-born child is more apt to be the 
victim of the disease than the children born later. 

Descent from the father, also known as seminal transmission, is more 
common than infection from the mother. In such cases, and provided 
no lesions exist along the genital tract, the seminal fluid will not cause 
a chancre if inoculated into a normal being, yet it carries with it the 
infection when fertilizing the ovum. Sometimes, even under such 
circumstances, an. apparently healthy child may be born. Or a father 
who has acquired syphilis, yet at the time conception takes place is 
free from all evidence of it, may beget a child with a most virulent 
form of the disease-. 

Descent from the mother may occur in three ways: 

1. Infection prior to conception. 

2. Infection at the time of conception. 

3. Infection following conception. 

When infection occurs at the time of conception, the case is one of 
paternal heredity, due to the syphilitic spermatazoa of the father. 
If the mother alone has syphilis, the disease may be transmitted, but 
the chances of transmission are much less than when the father alone 
is infected. If, at the time of conception, the mother is the subject of 
tertiary symptoms of the disease, there is great probability that the 
child will escape. 

Maternal infection exerts a more harmful influence than infection 
from the father, because of the dyscrasia which already exists in the 
mother, and produces lesions of the placenta which interfere with the 
maternal blood supply, and which, if these lesions involve a large 
part of the placenta, will usually cause an abortion. If, however, the 
placenta is only in part involved, the fetus is retained a longer period 
in utero, and may even be born dead at full term, or alive with the 
evidences of syphilis more or less marked. Infection during gestation 



740 THE SPECIFIC INFECTIOUS DISEASES 

can be transmitted to the fetus up to the eighth month, after which 
time the chances of escape are highly probable. 

Descent from both parents, also known as mixed heredity, is fairly 
certain if both parents are suffering from syphilis at the time of con- 
ception, and the virulence of the disease is greater than in hereditary 
disease of either maternal or paternal origin alone. 

A healthy mother may give birth to a syphilitic child, this child 
not being capable of infecting its mother either by nursing or other- 
wise, and the mother remaining apparently free from the disease ; yet 
such a child is capable of infecting a wet nurse. This is known as 
Colle's law. 

Furthermore, it is possible for a syphilitic mother to give birth 
to an apparently healthy child, the child in all probability having 
acquired a certain degree of immunity from the disease while in 
utero, or having merely a latent form of the disease (Profeta's 
immunity) . 

Lesions. — Skin. — Save for their severity the lesions of the skin are 
practically the same as those of acquired syphilis. Depending upon 
the time at which they appear, they show a certain degree of variation, 
being most intense at birth, and then usually either pustular or ulcer- 
ative. When they appear some weeks after birth, they are usually 
erythematous and papular in type. 

Erythematous Syphilides. — These develop usually during the third 
week of fetal life as minute spots which are of a pale red color, some- 
times confluent, and which disappear upon pressure. Usually they 
are seen on the face and about the genitalia, in this way differing from 
the roseola of acquired syphilis. This eruption is apt to be confused 
with simple erythema; but the gradual transformation into papules, 
which become scaly on the soles and palms, and yield readily to anti- 
syphilitic treatment, is a diagnostic feature. 

Papular Syphilides and Mucous Patches. — These are more apt to 
appear on the face, palms, soles, and buttocks, but may sometimes 
extend over the entire body surface. The papules have a tendency to 
group and coalesce, forming large flat papules. When they occur 
about the mouth they frequently develop into Assures, which bleed 
readily and upon healing leave a scar. When situated upon warm 
surfaces, they become denuded of their epithelial covering, and emit 
an offensive discharge. They are most frequently seen about the 
anus or mouth. Papular syphilides situated on the palms of the 
hands and soles of the feet are apt to show evidences of exfoliation. 
The fusion of a number of such papules On' the surface of the skin has 
a tendency to make the skin shed in large strips. 

Vesicular Syphilides. — This form is usually associated with the 
papular type, and appears as small blebs. Sometimes the contents 
of the vesicles become purulent, but this occurrence is rare, and 
usually accompanies only the more severe types of infection. 

Pustular Syphilides. — This type follows the papular eruption. In 
some cases the pustules may be seen at birth, in others they may not 



SYPHILIS 



741 



manifest themselves for a long time after the initial syphilid. The 
severity of the infection influences their character. They usually 
appear on the face, hands, soles, thighs, scalp, and buttocks. At times 
the eruption may assume the form of impetigo, acne, or ecthyma. As 
a rule, the pustular eruption produces permanent scars, and may 
result in extensive skin destruction should it be complicated by 
cellulitis and gangrene. 

Bullous Syphilides. — This form, also known as pemphigus, generally 
makes its appearance on the soles of the feet and the toes, the palms 
of the hand and the fingers, and the limbs. The eruption consists of 
blebs which are filled with a clear, turbid, or bloody fluid, are sur- 




Fig. 73. — Inherited syphilis in a child two months old. 



rounded by a slight areola on a base of reddish skin, and have a 
tendency to coalesce. The presence of such an eruption, together with 
lessened elasticity of the skin (because of a lack of subcutaneous fat), 
and a look of old age, should make one extremely suspicious of syphilis, 
particularly if the child is hoarse and has the snuffles. 

Tubercular and Gummatous Syphilides. — These lesions may occur 
at any age, but more often between puberty and the thirtieth year. 
They may be either ulcerative or dry in type, and usually appear 
first upon the face and the anterior surface of the legs in the form of 
dull reddish infiltrations which are painless, gradually increase in size, 
eventually ulcerate, and become encrusted. When ulceration does not 



742 THE SPECIFIC INFECTIOUS DISEASES 

occur, atrophic areas remain, whereas cicatrices which frequently 
produce marked deformities result from the ulcerative form. 

Mucous Membranes. — Coincident with the papular and papulo- 
pustular eruption on the skin is the appearance of similar lesions upon 
the mucous membranes, which appear in the form of mucous patches 
in the mouth. The mucous membrane of the pharynx, the mouth, the 
larynx, the ear, and the nose are all subject to this eruption. One 
of the earliest and most significant evidences of the disease is coryza, 
which is manifested by a discharge, at first watery, which when dry 
forms crusts, underneath which are minute ulcers. This in turn clogs 
the air spaces, causing difficult respiration, and the characteristic 
snuffles. The hoarseness which is so typical is the result of inflam- 
mation or even ulceration of the mucous surface of the larynx. When 
there is marked infiltration, the air passages may be so narrow as to 
produce dyspnea and occasionally, though rarely, death. 

Tertiary lesions of the disease manifest themselves usually at or 
about puberty, and are of the same nature as those seen in the adult. 
Infiltrations extend to various depths, and quickly break down, leav- 
ing marked degrees of ulceration. Such ulceration is apt to be found 
chiefly about the soft palate, the hard palate, the posterior pharyngeal 
wall, and the mucous membrane of the nose, resulting in marked 
deformity. 

Bones. — Bone changes which are found in a syphilitic fetus, whether 
it be stillborn or dies after birth, show a marked degree of uniformity. 
The long bones are the ones chiefly affected, and the changes are found 
at the epiphyseal junction. In the early stages of the disease there is 
proliferation of the cartilage cells, followed by softening at the epiphy- 
seal junction, and resulting detachment of the epiphyses from the shaft. 
As the disease progresses, certain degenerative changes occur, which, 
owing to infection by pus organisms, result in the formation of abscesses 
about the joint, or they may extend to the medullary cavity and result 
in osteomyelitis. 

Liver. — Changes invariably occur in this organ. Usually there is a 
more or less diffuse interstitial hepatitis, which makes the organ 
distinctly larger. 

Lungs. — Changes in these organs are more apt to result from 
hereditary than from acquired syphilis. They usually manifest them- 
selves in the form of gummata or as a diffuse infiltration, the latter 
condition ' being known as white pneumonia. Microscopically the 
alveoli are found to be filled with fatty, degenerated epithelial cells. 

Spleen. — The spleen is frequently the seat of a diffuse interstitial 
splenitis, and often increases to three or four times its normal size. 
When found during the first three months of life, it is of some diag- 
nostic significance, especially if accompanied by other evidences of 
the disease. 

Pancreas. — This also becomes the seat of a diffuse interstitial pan- 
creatitis, but is usually not accompanied by sufficient symptoms to 
permit its detection. 



SYPHILIS 743 

Kidneys. — These, too, may undergo interstitial changes, and in a 
certain percentage of cases albuminuria is present. 

Stomach and Intestines. — Ulceration and gummatous infiltration may 
attack these organs, but so rarely that such changes are of little or no 
importance. 

Circulatory System. — Interstitial myocarditis and endarteritis are 
the usual lesions, and the latter, if severe, may result in thrombosis. 

Lymphatic Glands. — Those most frequently affected are the anterior 
cervical group, as well as those groups which are subject to tubercular 
invasion, though the changes produced differ from tuberculous involve- 
ment in that the enlargement is slow and painless, and even though they 
attain a great size there is no suppuration. 

Nervous System: Brain. — This organ, when involved, is usually 
the seat of multiple and diffuse lesions which produce symptoms of 
varying nature. Fortunately its involvement is not common in chil- 
dren, but hydrocephalus is sometimes seen in the newborn who suffer 
from syphilis, and gummatous infiltration may be present at birth. 
Some children manifest the disease by retarded development of the 
brain; in these cases speech is difficult, and there is a varying degree 
of weakness which causes a staggering gait. Meningitis, basilar in 
type, may manifest itself and become chronic. Involvement of the 
spinal cord results in paralysis of either the upper or lower extremities, 
according to the location of the lesion. 

Eye. — Interstitial keratitis is one of the most constant lesions of 
hereditary syphilis, and usually makes its appearance between the 
seventh and fourteenth years. 

Ear. — Otitis media may develop owing to extension of the inflam- 
mation from the Eustachian tube. It frequently produces deafness, 
and may involve the mastoid cells. 

Teeth. — The first teeth exhibit no peculiarities of any importance, 
save that they soon decay. It is in the second or permanent teeth, 
chiefly the upper central incisors, that we find the characteristic 
evidences of syphilis. The so-called Hutchinson's teeth have a shallow 
crescentic notch in the cutting edge. All cases of hereditary syphilis 
do not, however, manifest these changes; in fact, the teeth may show 
varying degrees of deformity. 

Early Syphilis. — The early diagnosis of this disease depends upon 
several factors, chief of which is accurate information given by the 
parents of the presence of syphilis in either parent, or a history of 
frequent miscarriages, abortions, or stillbirths, or a history of several 
children having been born apparently healthy, but who survived 
only a short time. Such knowledge is of great importance. A child 
may show little or no evidence of the disease, or there may be an 
eruption on the body of pustules and papules, or bulla? upon the soles 
and palms. The liver and spleen are usually greatly enlarged, and 
there may be evidences of interstitial pulmonitis or white pneumonia. 
Hydrocephalus also may be present. 

In many cases the syphilitic fetus is dead at birth, and at postmortem 
the viscera, bones, and skin all exhibit signs of fully developed lues. 



744 THE SPECIFIC INFECTIOUS DISEASES 

In other instances the infant is born alive, but is emaciated, and bullae 
develop on the hands and feet. The bridge of the nose may be markedly 
depressed, and there is a persistent coryza, termed snuffles. Fissures 
and ulcerations (rhagades) appear about the lips and anus. The liver 
and spleen are enlarged. 

Disturbances of nutrition soon arise despite careful feeding, and 
emaciation is progressive. The facial expression is that of a little old 
man. A diffuse papular and papulovesicular rash usually appears 
soon after birth, and the skin of the face may assume a copper color. 
These infants rarely survive. 

In instances where the child at birth is to all appearances healthy, 
the symptoms of the disease usually do not manifest themselves until 
between the third and sixth weeks. Sometimes the first evidence is 
progressive emaciation, but usually coryza is the earliest symptom, 
and is frequently regarded as a simple cold. Coincidently there may be 
hoarseness of the voice, followed by the appearance of an eruption of 
papules and vesicopapules, some of which become pustular, and on 
bursting form crusts upon the surface of the skin. Mucous patches 
and rhagades also develop in these cases, but condylomata are not as 
common as in the early cases. 

The skin on the soles of the feet, palms, knees, and nates is diffusely 
indurated, and the scaling may resemble eczema. Copper-colored 
areas may be seen on the thighs, and in some cases spread all over the 
body, giving the skin a mottled appearance. This is especially notice- 
able on the face, for these infants are usually pale and anemic, so that 
the copper-colored patches form a sharp contrast. The liver and spleen 
may or may not be enlarged. Pseudoparalyses may arise, and gastro- 
intestinal disturbances are common. 

The various joints of the body are tender as the result of acute 
epiphysitis. Syphilitic dactylitis may appear as early as the fourth 
week, and cause a fusiform swelling of one or more of the phalanges. 
It consists of gummatous infiltration of the periosteum and bone tissue; 
sometimes the overlying skin and soft tissues become involved. In 
neglected cases, necrosis of the epiphysis and destruction of the joint 
occurs, and may result in fistula formation. The loss in weight is 
steady, the child becomes marasmic, and may die. 

The differential diagnosis between syphilitic and tuberculous dac- 
tylitis is very difficult; but there is usually more involvement of the 
soft tissues in the tuberculous form. 

The Wassermann and von Pirquet reactions are valuable aids, 
and a therapeutic test may be made by placing the patient on anti- 
syphilitic treatment. Craniotabes and bossing of the skull are bony 
changes which, if present, are always strongly suggestive of syphilis. 

The spirocheta may be found in the blood, internal organs, skin, 
and the lesions in the mucous membrane; but it is difficult to demon- 
strate, and the Wassermann reaction of the blood is a much simpler 
method of determining the presence of lues. If, after the blood test, 
there is still doubt, the Wassermann or Noguchi reaction should be 
done upon the spinal fluid. 



SYPHILIS 745 

Late Hereditary Syphilis. — The disease may make its appearance 
at any time prior to the age of puberty. It may or may not he preceded 
by early symptoms of congenital lues. In some cases the evidence- of 
syphilis are continuous with infantile lues, the child having always 
presented some stigmata of the disease, such as iritis or syphilides, 
but other children apparently enjoy good health with no eruptions or 
other symptoms until late in childhood, when one or. more syphilitic 
manifestations appear. In all probability, however, these are cases 
in which the early symptoms were so mild as to escape attention. 

The symptoms at this time correspond closely to those of the tertiary 
stage in the acquired form of the disease. There are evidences of 
arrested development, the complexion is of a peculiar leaden hue, the 
hair becomes brittle, and the nasal bone may be destroyed, thus pro- 
ducing a flatness of the bridge of the nose. The cornea may be hazy 
as a result of interstitial keratitis. The hard palate and nasal septum 
may be perforated, the teeth may show the characteristic crescentic 
notches, particularly the upper central incisors, and scars may form 
about the lips and nose. Enlargement around the epiphyseal junction, 
and deafness, either partial or complete, are characteristic evidences 
of the late form of the disease. 

Dwarfism and infantilism are often caused by syphilis, and are due 
to lack of development of bone and muscle. At puberty there is but 
a scant growth of axillary and pubic hair, and the organs of generation 
are abnormally small. The face is characteristic, with its lustreless 
skin, prominent forehead, depressed bridge of the nose, and asymmetric 
skull. Hutchinson's teeth and interstitial keratitis often complete the 
picture. 

The Hutchinson triad, i. c, syphilitic deafness, interstitial keratitis, 
and notched teeth, comprise a symptom-complex which, whenever 
present, is conclusive evidence of syphilis. The bone lesions of late 
syphilis consist of osteoperiostitis of the long bones and cranium, also 
dactylitis. 

Prognosis. — In every case this depends upon the extent of the lesions. 
In consequence of the changes due to the infection, such children are 
most susceptible to intercurrent affections. The age at which the 
disease makes its appearance, and the promptness with which treat- 
ment is instituted greatly influence the prognosis. 

The breast-fed infant with syphilis has a far better chance for life 
than the bottle-fed baby, but infant mortality due to syphilis is very 
high. More than one-third of syphilitic infants are born dead, and of 
those born alive more than one-third die before they are six months 
old. The longer the interval between birth and the first manifestation 
of the disease, the better the prognosis. 

Treatment. — This should be instituted as early as possible, partic- 
ularly in cases where there is a history of the disease in the parents, 
or of miscarriages, abortions, and stillbirths, or if a child exhibits any 
symptoms whatsoever of the disease. Mercury should be administered 
just as in the acquired form, and may be given either in inunctions, 
by mouth, or hypodermically ; in children inunctions are preferable, 



746 THE SPECIFIC INFECTIOUS DISEASES 

10 to 15 grains of mercurial ointment being used daily. The ointment 
should be rubbed in over a different area each day, in order to prevent 
erythema. 

If given by mouth, either the bichloride or calomel may be given, 
of the former ^ to -g^, and of the latter T V to -^ of a grain, three or 
four times daily. When there are lesions of tertiary nature the iodides 
should be administered, either alone or in combination with mercury. 
In view of the fact that in children the iodides have little tendency to 
upset the stomach, relatively large doses may be administered with 
little or no derangement of digestion; usually 10 to 20 grains daily 
are sufficient. 

The duration of the treatment should be regulated almost entirely 
by the symptoms. It is never advisable to continue it for long periods 
of time without an intermission. As there is usually some degree of 
anemia from the vigorous treatment, tonics in the form of iron, the 
saccharated carbonate, 1 or 2 grains, three times a day, should be 
administered. The syrupi ferri iodidi may be given in 10- to 20-drop 
doses. The child should have plenty of fresh air, and careful hygiene 
and hydrotherapeutic measures should be instituted to build up the 
general health. 

The local treatment consists in the dusting of powders, such as 
bismuth and calomel, upon the ulcerated areas, and the cauterization 
with nitrate of silver of the ulcerations upon the mucous membranes. 
If rhinitis is severe, the nose should be irrigated daily with a 1 to 2000 
solution of bichloride, and iodoform ointment may be applied to the 
inside of the nares. The mouth also should be washed daily with a 
2 to 5 per cent, solution of potassium chlorate to prevent salivation 
while mercury is being given. 

Salvarsan offers a speedy check to the active ravages of syphilis, 
and may be given to children in the dose of | grain for every 60 kilos 
of body weight. This treatment should be carried out only by one 
thoroughly conversant with the technic, and the patient should be 
taken to a hospital. Mercurical treatment should follow the injection. 

When epiphysitis is present the arm should be put in a splint with 
the elbow bent at a right angle, and the legs placed in straight splints 
if the lower extremities are involved. In these cases daily applications 
of unguentum hydrargyri should be used locally in addition to internal 
medication. 

In both infants and older children, the nutrition should be carefully 
watched. An otherwise healthy syphilitic mother should nurse her 
child; if this is impossible, a syphilitic wet nurse may be obtained, 
or the child may be given a carefully modified milk formula. The 
diet of older children should also be regulated. 

Where the treatment has been carried out continuously for a year, 
and there have been no active symptoms for six months, the disease 
may be regarded as well under control. Intermittent treatment, 
however, should be kept up for a year or two more before the case can 
be considered cured. During intermittent treatment the child should 
be given antisyphilitic treatment for six months of every year. 



CHAPTER XXIII. 
RHEUMATISM. 

ACUTE ARTICULAR RHEUMATISM. 

A discussion of acute articular, or acute inflammatory, rheumatism 
covers but a small part of the study of rheumatism, for in children 
of a rheumatic diathesis the manifestations of the disease may be 
numerous, varied, and peculiar. Arthritis, so typical of rheumatism 
in the adult, is often but an insignificant feature or may be wholly 
absent; but the skin frequently shows the effects of the toxins of 
rheumatism by the appearance of urticaria, erythema multiforme, 
erythema nodosum, or purpura. 

The cardiac manifestations of this disease are by far the most 
serious and, unfortunately, are by no means uncommon. They 
include endocarditis, myocarditis, and, occasionally, pericarditis. 
The kidneys are less frequently affected, but nephritis is occasionally 
the sequel to an attack of rheumatism. Chorea is the most common 
neurosis associated with rheumatism, the relation between these 
two diseases being so close that chorea is now regarded as essentially 
of rheumatic origin. Tonsillitis of rheumatic origin is a well recog- 
nized clinical entity; and, inversely, many cases of articular rheuma- 
tism are now believed to be due to infection which has its source in 
the tonsils. 

Torticollis may also be due to rheumatism, especially when its 
onset is sudden, and it is ushered in by a spasm of the cervical muscles 
caused by the irritation of the rheumatic toxins. Other muscles of 
the body may be affected in like manner; but rheumatism is rarely 
the diagnosis in these cases, the symptoms being usually referred to 
as "growing pains" when they occur in the legs, or as "a stitch in 
the side" when the intercostal muscles are affected. 

Barlow and Warner, in 1881, described the rheumatic nodule, 
which is an oval, semitransparent, fibrous body looking like a boiled 
sago grain. These nodules most frequently form at the back of the 
elbow over the malleolus, and at the margin of the patella. Occasion- 
ally they may be found on the extensor tendons of the hands, fingers, 
and toes, or over the spinous processes of the vertebrae. They are 
composed of fibrin cells and fibrous tissue, and vary in size from a 
pin's head to a small pea, exceptionally attaining the size of an 
almond. They usually appear in crops, and may remain for months, 
but generally disappear within a few weeks. 

Among the rarer manifestations of rheumatism in children may 
be mentioned mastitis, periostitis, and peritonitis. In many instances 
these diverse signs of a rheumatic diathesis are so slight and transi- 



748 RHEUMATISM 

tory in nature that their rheumatic origin is overlooked; but, at one 
time or another, these children suffer from more or less typical attacks 
of acute, subacute, or chronic articular rheumatism and in these 
seizures clearly defined symptoms appear which reveal the true 
nature of previous vague symptoms of the disease. 

Etiology. — Heredity is regarded as one of the most potent causes 
of rheumatism in children as well as in adults, and in such cases the 
family history often reveals rheumatic affections in older members 
of the family, as well as in the young brothers and sisters of the child. 

Acute articular rheumatism may appear in typical attacks at any 
age from infancy to adult life; but, until the tenth year, it is usually 
atypical. Infants are rarely attacked; it is uncommon between the 
second and fifth years; but in older children it occurs more often, and 
is most frequently observed between the ages of ten and twenty. 
Girls are more prone to chorea than boys, but otherwise there is little 
difference in the incidence of the disease in the two sexes. 

Rheumatism is most prevalent in the spring of the year, and is 
also precipitated by exposure to cold and wet. It is more common 
in the poorer classes, a fact which is probably explained by the damp 
dwellings, unsuitable and insufficient food, and unhygienic surround- 
ings which are factors in its causation. One of the most unfortunate 
features of rheumatism is the influence one attack of the disease has 
in producing another; for, once a sufferer from rheumatism, there 
is always a strong tendency to future attacks. 

Many cases follow attacks of tonsillitis, and occasionally rheuma- 
tism accompanies scarlet fever and influenza. Several theories have 
been advanced as to the actual cause of rheumatism; but in recent 
years the recognition of its infectious nature has steadily gained favor. 
Furthermore, the theory of its microbic origin has been strongly 
supported by the occurrence of epidemics, and by the discovery of 
a diplococcus by Triboulet, Wassermann, Pointen, and Payne. This 
organism is, in all probability, the specific germ, since it is capable 
of producing various manifestations of rheumatism when injected 
into the lower animals. 

At one time a so-called nervous theory of rheumatism was in vogue, 
but this is now largely discredited: Its adherents contended that 
rheumatism was caused by a disturbance of the nerve centres pro- 
duced by cold, and that a derangement of metabolism resulted from 
the primary disturbance of the nervous system. In consequence of 
poor metabolism, the nitrogenous bodies were concentrated into uric 
acid and deleterious substances instead of urea. 

Other observers have claimed that rheumatism is due to defective 
assimilation, whereby are formed certain acids, among which lactic 
acid is held to be largely responsible in the production of the symptoms 
of this disease. 

Pathology. — The pathological changes in acute articular rheumatism 
are slight and not at all characteristic. The synovial membrane of 
the affected joints is intensely hyperemic and inflamed, and there 



ACUTE ARTICULAR RHEUMATISM 749 

is frequently an accompanying inflammation of other serous surfaces 
of the body. Within the joint is an effusion of turbid fluid which 
contains leukocytes and flakes of fibrin, and is usually sterile. 

The periarticular tissues are also infiltrated with this exudate, 
causing a swelling about the joints, and there may be an associated 
inflammatory condition of the tendon sheaths. In protracted cases 
the cartilage may* become eroded; but, as a rule, there are no perma- 
nent changes within the joint. Exceptionally the exudate in the 
joint cavity becomes purulent. 

The characteristic changes in the heart are due to the effect of 
bacteria or the toxins of rheumatism on the endocardium. They 
consist in a hyperplasia of tissue which forms vegetations on the mitral 
valve and, as a rule, prevents perfect apposition of the valve leaflets 
and complete closure of the valve. 

There are also pathologic changes in the myocardium, pericardium, 
pleura, and, rarely, in the peritoneum and meninges; but these prac- 
tically amount to merely an inflammatory state, and are nowise 
pathognomonic. 

The fibrin elements of the blood are increased, and fibrinous clots 
are found in the heart and great vessels. In addition, there is severe 
secondary anemia with a marked reduction in the number of red 
cells. Proliferative periostitis and subcutaneous fibrous nodular 
deposits are among the rarer pathological findings. 

Symptoms. — The symptoms of acute articular rheumatism in the 
child differ greatly from its manifestations in the adult. The articular 
symptoms which form so prominent a feature in later life are much 
less distinctive, and fewer joints are involved. The pain and swelling 
in these joints are usually slight, and there is frequently no redness. 
In the ordinary case the fever is never very high, and is not of extended 
duration. 

The onset is not acute, but is often preceded by a few days of malaise, 
with sore throat, anorexia, abdominal pain, and occasionally vomiting. 
The pains about the joints at this time are transitory and indefinite. 
After this there is commonly fever of 100° to 101° F., and the joint 
becomes swollen and tender; if the ankle, knee, or hip is involved, 
the child^ is unable to walk. 

In mild cases there is merely stiffness in the affected joint, causing 
the child to limp if the leg is attacked. The knee- and ankle-joints 
are most often involved; next in frequency are the small bones of 
the feet, the elbows, and wrists. Muscular spasm is not uncommon. 
In some instances there is extreme tenderness about the muscles and 
tendon sheaths, the joint being but little affected; this gives rise to 
the so-called "growing pains" of children, which are often of much 
more serious nature than is generally supposed. 

The urine in these cases is highly colored, concentrated and 
decreased in amount. The profuse acid sweats so characteristic of 
rheumatic fever in the adult are not as frequently observed in young 
children, the skin being more often hot and dry. While of mild type, 



750 RHEUMATISM 

this atypical form of rheumatism in the child is apt to run a relatively 
longer course than in the adult, many of the cases being subacute, 
although a chronic affection is rare. 

Owing to the predisposing influence of one attack of rheumatic 
fever upon another, recurrences are likely to happen from time to 
time throughout childhood, and even during adult life. 

Rheumatic Symptoms in Older Children. — The atypical type of 
rheumatic fever just described is characteristic of most attacks 
observed in children up to the age of eight years, after which the 
symptoms of the disease conform more or less to the adult type. 
The attack comes on suddenly with acute inflammation of one or 
more of the larger joints. Pain is agonizing, and tenderness so 
exquisite that any attempt to palpate the joint causes the child to 
cry out in anticipation of the pain. 

The skin over the joint is usually of a red and dusky hue, hot to 
the touch, and edematous. The temperature ranges from 102° to 104° 
F. on the first day, but there are marked variations in its course, and 
it finally declines to normal by lysis. Sweating is profuse, and its 
peculiar acid odor is characteristic. Sometimes the skin is hot and 
dry. The bowels are usually constipated, the tongue is dry and 
coated. 

A distinguishing peculiarity of the disease is the order in which 
the joints are affected, the inflammation appearing in a fresh joint, 
or set of. joints, as it subsides in the one originally affected, so that 
the disease is seemingly transferred from one articulation to another. 

Cardiac symptoms, while not uncommon, occur less frequently in 
these cases than in subacute attacks, in which the joint symptoms 
are mild and relatively unimportant. 

Extra-articular Symptoms. — In children, especially, involvement 
of the heart is of such frequent occurrence that it can be reasonably 
regarded as a sign or symptom of rheumatic fever. Either the endo- 
cardium, pericardium, or myocardium may be affected, and in severe 
cases all three are inflamed; but endocarditis is the usual finding. 
In many instances it follows an attack of rheumatism so mild that 
it is impossible to obtain a history of the illness from the parent. 

There are no special symptoms which attend the onset of endo- 
carditis, and it is rarely fatal during its acute stage, but tends to 
develop subacute or chronic lesions which incapacitate or destroy 
life months or even years after the rheumatic attack. The mitral 
valve is almost invariably the site of the endocardial lesion; in most 
of the other cases the aortic leaflets show changes; occasionally both 
mitral and aortic valves are involved. This acute inflammation of 
the endocardium is usually of simple verrucose type, and is indicated 
by an apical blowing systolic murmur and by the reduplication of 
the cardiac second sound. 

There may be, and frequently is, an increase in the height of the 
fever when endocarditis sets in, and also a certain amount of palpi- 
tation, dyspnea, and precordial pain. Even when there is no endo- 



ACUTE ARTICULAR RHEUMATISM 751 

carditis, the pulse is increased to 120 or 130 per minute, and is soft 
and full; therefore in these cases, unless the pulse is decidedly irregu- 
lar, tachycardia is of no diagnostic value in determining the presence 
of a heart lesion. 

Pericarditis, while not so frequent as inflammation of the endo- 
cardium, is not extremely rare in older children, and may sometimes 
be seen in association with endocarditis. The inflammation is, as 
a rule, of a dry fibrinous type, the effusion consisting chiefly of organ- 
izable lymph, often in large amounts. This results in numerous 
adhesions and, on account of the tendency to recurrence which is 
characteristic of this form of pericarditis, the pericardial sac may 
eventually become almost obliterated. 

The most important symptom is a to-and-fro friction sound, which 
is pathognomonic of pericarditis. A slight degree of myocarditis 
is often present with either endocarditis or pericarditis, but is more 
marked when there is endocarditis. 

Skin Lesions. — These are seen more frequently in children than 
in adults, and usually manifest themselves by the development of 
purpura or erythema. The relation between the various forms of 
erythema, — simplex, urticaria, nodosum, multiforme, and marginatum, 
— is not as yet clearly understood. Erythema multiforme is the most 
common erythematous lesion caused by rheumatism; urticaria is not 
uncommon, but erythema nodosum is rare. 

Owing to its frequent association with rheumatism, purpura in 
these cases receives the name of purpura rheumatica. But purpura, 
although not uncommon in rheumatic children, also accompanies 
other diseases; therefore it is probable that these extravasations 
under the skin are due to an accompanying infection rather than to 
rheumatism itself. 

Sudamina and miliaria may appear as the result of overactivity 
of the sweat glands, and herpes also is occasionally observed in rheu- 
matic children. Rheumatic subcutaneous nodules, which have already 
been described, while more common in children than in adults, are 
rarely seen in the eastern section of the United States; but when they 
appear in children, they may be regarded as a positive sign 
of rheumatism. 

The Blood. — Examination of the blood in acute rheumatic fever 
usually reveals a rapidly developing and severe secondary anemia 
with a decided decrease in red cells and moderate leukocytosis. Blood 
cultures are usually negative, but diplococci have been isolated from 
the blood in severe attacks of rheumatic fever. 

Muscular Symptoms. — The muscular symptoms of rheumatism 
consist chiefly of inflammation of the muscles and tendons about 
the affected joints, and there is usually considerable swelling and 
tenderness in these soft tissues. In protracted cases of rheumatism 
some degree of atrophy may follow. 

Tonsillitis. — Sore throat, especially tonsillitis, often accompanies 
attacks of rheumatism in children, and sometimes precedes the articu- 



752 , RHEUMATISM 

lar symptoms. Some rheumatic children, however, who present no 
articular symptoms, are also subject to attacks of tonsillitis. Follicular 
inflammation of the tonsils is the common form in these cases, although 
there may be a peritonsillar abscess. 

The- ordinary sore throat associated with rheumatism in children 
usually lasts only three or four days, but its subsidence has no appre- 
ciable effect upon the duration of the articular or cardiac symptoms, 
or upon their severity. 

The Respiratory Tract. — As a rule, the organs of respiration are 
but slightly involved, but there may be a moderate degree of bron- 
chitis, and occasionally pleurisy. Pneumonia is quite rare, and usually 
assumes the lobular type. Inflammation of the pleura in these cases 
is usually serous, but may be fibrinous. The chief symptom of pleurisy 
is thoracic pain. Friction fremitus is rarely heard over a large area 
of the chest wall. As a rule there is no decided rise of temperature 
with the onset of pleurisy, and but little increase in the severity of the 
constitutional symptoms. The left chest is most frequently affected. 
In some instances the pleura becomes inflamed through extension 
from the pericardium. 

Although few cases of pneumonia can be clearly demonstrated 
to be of rheumatic origin, yet in several instances a diplostreptococcus 
has been isolated from the sputa in pneumonia, and also from the 
pleural effusion. 

Nervous Manifestations. — Chorea is the most common nervous 
affection related to rheumatism, and may precede, accompany, 
or follow a rheumatic attack. Sometimes it accompanies endocar- 
ditis, and there are no articular symptoms. More than one-half the 
children who are subject to chorea are of a rheumatic diathesis, while 
those who suffer frequently from rheumatism are usually neurotic. 
Headaches are common among these children, they are easily excited, 
frequently suffer from night terrors, and display other evidences of 
a nervous temperament. 

These nervous phenomena are probably due to three causes — 
nervous irritation and exhaustion, high fever, and profound toxemia. 
In uncomplicated cases of rheumatic fever delirium is rare; but its 
appearance may sometimes signify pericarditis, while in others it 
may be due to an overdose of the salicylates. Convulsions are uncom- 
mon, coma is rare, and meningitis is only exceptionally a complication 
of rheumatism in children. 

Diagnosis. — When typical acute articular rheumatism occurs in 
children it is usually easy of recognition; but since cases are atypical, 
especially in young children, and in some there is no appreciable 
joint lesion, the disease is quite often unsuspected. In attempting 
to arrive at a diagnosis of rheumatism, the family and personal 
history of the child are important, as well as the articular manifes- 
tations. Other signs, such as erythemata, tendinous nodules, growing 
pains, chorea, sore throat, and pains in the epigastrium and chest, 
must also be analyzed if the disease is to be recognized in its varied forms. 



ACUTE ARTICULAR RHEUMATISM 753 

An examination of the heart in a suspicious case may often reveal 
the presence of endocarditis, which is a great aid to the diagnosis 
of rheumatism in those cases in which there is no joint involvement. 
The diagnostic points in a typical attack of inflammatory rheumatism 
in a child are as follows: a history of rheumatism in the family and 
of repeated attacks of sore throat; inflammation of one or more of 
the large joints with a tendency to shift from one joint to another; 
and signs of endocarditis. 

In infancy rheumatic arthritis is so rare that many other conditions 
common at this time of life should be considered before such a diag- 
nosis is made. In infants, scurvy is often mistaken for rheumatism, 
and the differentiation may be difficult until demonstrated by the 
characteristic state of the gums. There is, however, but little fever 
in scurvy; there is almost always pain and swelling in the lower 
extremities, the ends of the long bones being involved, as a rule, rather 
than the joints. Antiscorbutic treatment will demonstrate the pres- 
ence of scurvy in a few days, and serves in these cases as a thera- 
peutic test. Acute rheumatism must also be differentiated from scar- 
latinal arthritis; but in the latter disease there is a history of scarlet 
fever symptoms. Moreover, as the disease generally comes on in the 
second or third week, the child is usually desquamating. Scarlatinal 
arthritis shows a marked tendency to involve the wrists, while, as 
a rule, in acute rheumatism, the larger joints are attacked. True 
rheumatic arthritis may come on during an attack of scarlet fever, 
and here the diagnosis is extremely difficult. 

Septic arthritis occurring in the course of pyemia, and the poly- 
arthritis occasionally observed just after birth, may be confounded 
with rheumatic arthritis in its early stages; but, as a rule, suppuration 
accompanies these affections, and the constitutional symptoms of 
septic arthritis are much more severe than those of rheumatism. 
In gonorrheal arthritis there is usually a history of vulvovaginitis, 
the disease being most prevalent in girls; the knee-joints are the 
ones most frequently involved. 

Acute osteomyelitis may produce symptoms much like those of 
rheumatism, and this affection should be excluded in every case, 
its early recognition being most important. The femur is the most 
common site of osteomyelitis, it usually attacks only one long bone, 
and involves only one joint. Both the local and constitutional symp- 
toms are more severe than those of rheumatism. 

Tuberculous arthritis may be difficult to exclude. It is strongly 
suggested when there is a slight attack of rheumatism in the hip- 
joint; but the course of tuberculous bone disease is essentially chronic, 
there is less induration about the joint, and the pain is greatest within 
the joint. 

Pneumococcal arthritis is acute, but is the sequel to pneumonia, 
and diplococci may be found in the exudate within the joint. As a 
rule suppuration sets in, and simplifies the differentiation from rheu- 
matism, since the rheumatic joint rarely, if ever, suppurates, 
48 



754 RHEUMATISM . 

Epidemic cerebrospinal meningitis with extreme and unusual 
tenderness of the joints may suggest rheumatism; but, upon careful 
study, the reflexes will be found abolished, there is severe headache, 
and the cerebrospinal fluid shows acute meningeal inflammation. 

Syphilitic arthritis is usually monarticular, but may occasionally 
be mistaken for rheumatism; there is, however, the usual history of 
syphilis in mother and father of the child; and, on careful examina- 
tion, concomitant signs and symptoms may be found. If necessary, 
a Wassermann reaction will determine the existence of lues in these 
cases. 

Intra-abdominal Complications. — These are rare, but peritonitis 
is occasionally seen together with inflammation of other serous 
cavities; sometimes these children suffer from a nervous diarrhea 
which brings on defecation just before or during a meal. Epigastric 
pain is a puzzling symptom more or less confined to children who 
suffer from rheumatism; it may either be due to a rheumatic state 
of the abdominal muscles or simply be caused by an associated gastric 
catarrh. As a rule, there is no tenderness over the epigastrium, 
and the pain usually disappears early in the rheumatic attack. There 
are no gross lesions of any of the abdominal viscera, although the 
spleen is often enlarged. 

Epistaxis is not of rare occurrence in rheumatic attacks during 
childhood, and is rather an ominous sign because of its association 
with endocarditis. Iritis also appears in some cases, owing to the 
lodgment of rheumatic organisms in the fine capillaries of the iris. 

Course and Prognosis. — In children the articular symptoms of 
rheumatism usually subside within a week or two; but exceptional 
cases may be protracted for several weeks or even months, while 
in some cases recurrences are so frequent that the children are prac- 
tically never free from rheumatic manifestations. 

Recovery from ,an acute attack depends to a certain extent upon 
the mode of treatment and the promptness with which it is instituted; 
but, if there are no complications, the outlook is favorable. Unfor- 
tunately, however, children are much more liable to grave compli- 
cations, such as endocarditis and pericarditis, than adults; therefore, 
rheumatism in childhood is a serious disease. With each relapse 
fresh damage is done to the heart; and, while cardiac involvement 
in an acute attack rarely proves fatal, the damage to the heart even- 
tually results in death. The appearance of rheumatic nodules is 
regarded as a particularly unfavorable sign in rheumatism, since 
they are usually associated with cardiac complications. 

Treatment. — Rest in bed is the most important and essential measure 
in the treatment of acute rheumatism in children. By observing 
this precaution, much can be done to prevent the greatly dreaded 
cardiac complications of the disease. It is difficult to state definitely 
how long the child shall remain in bed, and also hard to keep a child 
in bed after the acute symptoms of rheumatism have subsided; but 
such grave consequences may follow if these children play about too 



ACUTE ARTICULAR RHEUMATISM 755 

soon that, to be perfectly safe, they should be kept in bed for a month 
after an attack of acute rheumatic fever. The sick-room should be 
well aired, the temperature kept at about 70° F., and all draughts 
avoided. The child should wear a flannel night dress, and lie between 
blankets, to prevent any chilling of the surface of the body. 

The diet should at first be liquid but nourishing, consisting for 
the most part of cereals, milk, and egg albumen; later bread, vege- 
tables, and a little meat may be given, but it is wise to limit the 
amount of starches. An initial dose of calomel, 1 to 2 grains, should 
be administered, and may be followed by magnesium citrate, 2 to 6 
ounces, or 1 dram of magnesium sulphate, after which the bowels 
should be kept regular by giving, when necessary, smaller doses of the 
citrate or sulphate of magnesium. 

The joints may be wrapped in a layer of cotton wool and then 
loosely bandaged. In some cases the affected limb may be more 
effectually kept at rest by applying a light wooden or cardboard 
splint. 

If pain is severe, it is sometimes necessary to use a bed cradle to 
keep the weight of the bedclothing off the limbs; in these cases, 
particularly, the local application of methyl salicylate, ichthyol, 
or of ice-cold or warm compresses soaked in a saturated solution of 
sodium bicarbonate will often give relief. 

For high fever in rheumatism a tepid sponge may be given, and 
is less harmful than antipyretic drugs. The salicylates are specific 
in acute rheumatic fever, and should be given in full dosage, just 
as quinin is administered in malaria; for, thus taken, they may pro- 
tect the cardiac valves and myocardium and pericardium from injury 
by shortening the attack of the disease. From 10 to 20 grains of 
sodium or strontium salicylate, according to the age of the child, 
should be given every three or four hours, and it has been demonstrated 
that if equally large doses of sodium bicarbonate are administered 
with the salicylates, the results will be better than if the salicylates 
are used alone. When given liberally, the bicarbonate of soda also 
minimizes to some extent the injurious effects of the salicylates upon 
the stomach, and aids in protecting the heart. If the pain is not 
relieved by the treatment outlined, acetanilid may be given in \- to 
2-grain doses three times daily, or salol in 1- to 3-grain doses after 
meals. 

In the more obstinate, or subacute forms, of rheumatism the salicy- 
lates are frequently of less value, and better results are sometimes 
obtained by the use of potassium iodide, 3 to 5 grains, three times a 
day, or the citrate or bicarbonate of potassium, 10 grains every four 
hours. 

Lemon and lime juice in large quantities are very beneficial. These 
children should be encouraged to drink water freely, especially Seltzer 
and Vichy. 

Morphine should be given only when pain is severe; but some of 
the latest preparations of the salicylates may be used to advantage 



756 RHEUMATISM 

in children; among them aspirin, dose 3 to 7 grains, and novaspirin, 
5 to 10 grains three times a day. These are especially beneficial when 
the stomach becomes intolerant to sodium or strontium salicylate. 
Ammonium salicylate may be given in 5-grain doses every three 
hours, and sometimes methyl salicylate internally in 5- to 10-drop 
doses, every three hours. 

The heart should be examined carefully every day for any sign of 
dilatation of the left ventricle, for a systolic murmur, or imperfec- 
tion in the first sound, inasmuch as the onset of valvulitis or 
endocarditis is not accompanied by any subjective or objective 
symptom. 

When cardiac complications arise the child should be kept as quiet 
as possible, both mentally and physically, should use the bed-pan, 
and eat in a recumbent posture. If the heart is overactive, an ice- 
bag may be placed over it; if pericarditis is the cause of excessive 
cardiac action, tincture of aconite may be given in \- to 1-drop doses 
every four hours until free perspiration is induced. If myocarditis is 
present and the heart requires stimulation, strychnine sulphate, 4^- 
to -g-QT of a grain ; tincture of nux vomica, 1 to 5 drops, or \ to 1 tea- 
spoonful doses of brandy may be given every three hours. 

During convalescence children should take general tonics and 
receive special attention to prevent relapses. The anemia calls for 
iron, and 5 drops of the tincture of ferric chloride, or 5 to 20 drops 
of the syrup of ferrous iodide, may be given after meals. Sometimes 
iron causes indigestion and bodily pains, so that it must be discon- 
tinued; and cod-liver oil in teaspoonful doses, quinine in 1- to 3-grain 
doses, or elixir of glycerophosphates in teaspoonful doses, may be 
substituted. 

The diet should be highly nutritious, but care should be taken not 
to overfeed, and also to prevent constipation. Milk, eggs, green 
vegetables, fish, and chicken are allowable if the digestion is good, 
but, as a rule, it is best to limit the amount of red meats. 

If no heart lesions are detected, the child may be permitted to get 
out of bed two or three weeks after the fever has subsided and other 
symptoms have disappeared. If endocarditis is present, rest in bed is 
necessary for six or eight weeks after it is first noticed. In this case 
the heart should be carefully watched when the patient first sits up in 
bed, when he gets out of bed to sit in a chair, and when he walks; 
on the faintest sign of dilatation or undue strain, rest in bed should 
be again resorted to until the child can go about and take moderate 
exercise without apparently embarrassing the heart. 

The prophylactic treatment of rheumatism in children and the 
after-care of children who have suffered from rheumatic attacks are 
often matters of great difficulty. These cases need a diet that is 
easily digested and is nourishing, containing a high protein content 
and a limited amount of starches. Flannels should be worn next 
to the skin the year round. If practicable, these children should be 
taken south for the winter and spring. As a rule, the seashore air 



MUSCULAR RHEUMATISM 757 

is too damp; therefore, unless there is endocarditis, mountainous 
regions or moderate elevations provide the most suitable climate. 
Cold bathing is contraindicated; but a warm bath may be given 
each evening under proper precautions. When there is an endocardial 
lesion, violent exercise should be forbidden, games such as foot-ball, 
base-ball, and running races being very harmful. But moderate 
exercise is necessary, and the child should be encouraged to take short 
walks, and may amuse itself with croquet. Owing to the frequency 
with which rheumatism follows tonsillitis, the tonsils should be care- 
fully examined, and every case of tonsillitis receive immediate and 
efficient treatment. Surgical tonsils should be removed as soon as 
possible. 

MUSCULAR RHEUMATISM. 

Muscular rheumatism is rare in infancy and childhood, but the 
acute and subacute types are occasionally observed. 

Etiology. — The exact cause of the affection is unknown, but mus- 
cular rheumatism frequently follows exposure to cold or dampness. 
It is claimed by some authorities that disturbed metabolism exerts 
a predisposing effect upon this disease in causing the liquids of the 
body to contain a large quantity of toxic materials, which are precipi- 
tated into the muscle structure by cold or chilling. 

Another theory is that rheumatism of the muscles is caused by a 
streptococcus much like the one supposed to be the cause of articular 
rheumatism. Among the exciting factors are indiscretions in diet, 
constipation, great physical strain or fatigue, improper or insufficient 
clothing, and damp weather. One attack predisposes to another. 
The disease is most common in children who are of a rheumatic 
diathesis. 

Pathology. — The muscle fibers are swollen, and on cross-section 
show granular changes. Under the microscope in the acute form, 
which is really a myositis, we find round cell infiltration in the con- 
nective tissue and partial degeneration of the muscle fibers. 

Symptoms. — Muscular pain and stiffness are the most prominent 
symptoms. Fever is rare. Cardiac complications do not occur as 
frequently as in articular rheumatism. The usual sites of muscular 
rheumatism are the cervical muscles (torticollis), the intercostal 
muscles (pleurodynia), and the lumbar muscles. As a rule, there 
are no constitutional symptoms. 

Diagnosis. — This is usually easy to make, because of the location 
of the pain and the stiffness in the affected muscles; but articular 
rheumatism and neuritis must always be excluded. 

Prognosis. — The prognosis as to recovery is good. There is little 
danger of cardiac complications, but recurrences are common. 

Treatment. — When an attack of muscular rheumatism follows 
exposure, the child should have a hot Turkish bath, and then take 
3 to 6 grains of Dover's powder, in three doses, one hour apart, and 
be put to bed. Aspirin, 3 to 7 grains, salol 2 to 5 grains, acetanilid, 



758 RHEUMATISM 

gr. 1, or phenacetin in 1 to 2 grain doses, may be given three times a 
day. Hot compresses, a hot iron, or a hot-water bottle, placed over 
the affected muscles will often give relief. Chloroform liniment or a 
20 per cent, salicylic ointment may also be applied. 

A saline purgative, such as 1 dram of magnesium sulphate, or 
20 to 30 grains of Rochelle salts, should always be given at the onset; 
and, if the urine is acid and highly colored, 10 grains of sodium bicar- 
bonate in a glass of water may be administered three times a day. 
To prevent future attacks, these children should be protected from 
draughts and exposure, and should wear flannel or woolen under- 
garments the year round. Constipation should be corrected, and the 
diet carefully regulated. 

CHRONIC RHEUMATISM. 

Chronic rheumatism is rare in children, but may be the sequel 
of repeated acute attacks. It practically never occurs as a primary 
affection, chronic arthritic disease being usually due to some other 
cause, such as syphilis, tuberculosis, Still's disease, or rheumatoid 
arthritis. 

Etiology. — Since most cases follow a series of repeated attacks of 
acute rheumatism, the etiology of chronic cases is essentially the same, 
dampness, exposure to cold, and heredity being the most significant 
causes. 

Symptoms. — The symptoms are, for the most part, referable to 
the joints, which gradually become enlarged, painful, and immobile. 
As a rule, there are no constitutional symptoms. The course of the 
disease is protracted, although relatively shorter than in adults. 

Diagnosis. — Two diseases, Still's disease and rheumatoid arthritis, 
closely resemble chronic rheumatism, and in every case should be 
excluded when making the diagnosis. 

STILL'S DISEASE. 

This affection is a chronic polyarthritis, which usually appears 
before the child is five years old. It is characterized by stiffness 
and enlargement of the joints, and enlargement of the liver, spleen, 
and lymphatic nodes. 

Etiology. — The precise nature of the exciting factor in this disease 
is obscure, but it is believed to be chronic sepsis. Girls are affected 
in greater numbers than boys. Most cases occur before the eruption 
of the primary teeth. 

Symptoms. — Acute exacerbations are accompanied by fever and by 
tenderness in the affected joints; but the most marked features of 
the disease are a gradually developing ankylosis of the joints and 
swelling due to pathological thickening of the soft structures. There 
are no exostoses and no degenerative bone changes; but muscular 
wasting is often extreme. The lymphatic glands about the joints and 



RHEUMATOID ARTHRITIS— ARTHRITIS DEFORMANS 759 

throughout the entire body may be greatly enlarged, the liver and 
spleen hypertrophied, and the blood picture is that of severe anemia. 
Adhesions of the pleura and the pericardium are occasionally observed. 
Prognosis. — Since there are no destructive changes in the joints, 
the prognosis is somewhat more favorable than in other chronic 
joint diseases; but complete recovery is rare. 




Fig. 74. — Still's disease. 

RHEUMATOID ARTHRITIS— ARTHRITIS DEFORMANS. 

Rheumatoid arthritis is extremely rare in children, and is at first 
usually mistaken for chronic rheumatism. It is marked by thickening 
of the synovial membrane, by enlargement of the articulating surfaces 
of the bones, and, occasionally, by effusions into the joints. 

Etiology. — This disease is now believed to be infectious in origin, 
and the earlier theory that it originated in the nervous system has 
been largely discredited. It is usually the result of exposure to damp- 
ness and cold, and the infection is supposed to have its origin in 
decayed teeth, diseased tonsils, or other suppurating foci. 



760 



RHEUMATISM 



Symptoms. — In exceptional cases the onset of rheumatoid arthritis 
may be sudden, but, as a rule, it is slow. There is usually no fever, 
but the joints are painful and swollen, and gradually become worse. 
When the pain increases, motion becomes limited, and in protracted 
cases marked ankylosis and muscular atrophy occur. As the disease 
progresses, and additional joints are involved, pain on motion becomes 
more severe, and all movements of the body are restricted. The 
skin over the affected joints has a shining, waxy appearance, but 
there is no local heat, although the body temperature may rise a 
degree or so at intervals during the course of the disease. 




Fig. 75. — Still's disease. 



Diagnosis. — The differential diagnosis between the several forms of 
chronic arthritic disease is difficult at the onset, but can usually be 
made after careful study. Chronic rheumatism is characterized by 
stiffness in the joints, little or no deformity, and a history of repeated 
acute attacks; while in Still's disease there are both deformity of 
the joints and stiffness due to thickening of the soft structures, and 
also glandular hypertrophy. 

The chief diagnostic feature of rheumatoid arthritis is enlargement 



RHEUMATOID ARTHRITIC— ARTHRITIS DEFORMANS 761 

of the articulating ends of the long bones, which results in ankylosis 
and marked muscular atrophy. Syphilitic arthritis may simulate 
chronic muscular rheumatism; but children with luetic changes in 
the joints usually show other symptoms of syphilis, such as Hutchin- 
son's teeth and keratitis, and in doubtful cases a Wassermann should 
be made to clear the diagnosis. 

Tuberculous arthritis may be differentiated by the absence of 
tuberculous foci elsewhere in the body, the absence of fever and of 
.r-ray findings, and by the negative tuberculin reaction. 




Fig. 76. — Still's disease. Same patient as in Fig. 75, but one year later. 

Prognosis. — The prognosis is good as to life; but, as a rule, little 
can be done to relieve the condition of the joints. 

Treatment. — The treatment of chronic rheumatism and of other 
forms of chronic arthritis is much the same. In the syphilitic types, 
antisyphilitic treatment is usually effective. Tuberculous joints 
are best treated by putting them in a cast, but rest is not indicated 
in rheumatoid arthritis, Still's disease, or chronic rheumatism, and 
children suffering from these diseases should be encouraged to use 
the affected joints as much as possible, stopping short of fatigue. 



?62 



RHEUMATISM 



Warm bathing is very beneficial, and the affected joints should 
be massaged daily. Ichthyol is one of the best local applications, 
and a 25 to 50 per cent, ointment should be rubbed into the joint 
twice daily. In certain cases baking or dry hot air baths may be 
followed by marked improvement. Passive motion should be prac- 
tised each day, and adhesions broken up while the child is anesthetized. 




Fig;. 77. — Rheumatoid arthritis in a girl aged twelve years. 



If pain is severe, antipyrin or phenacetin may be given in 1 to 
2 grain doses, three times a day, or potassium iodide 1 to 5 grains 
at a dose after meals. Children who improve under this treat- 
ment are sometimes enabled to walk by using suitable orthopedic 
appliances. 



CHAPTER XXIV. 
SCURVY. 

Scurvy, or scorbutus, is a constitutional disease due to prolonged 
malnutrition. In about 50 per cent, of the eases it is associated with 
rickets, although these two diseases are essentially distinct. The 
chief characteristics of scurvy are a tendency to hemorrhage from 
the gums, the nose, and other mucous membranes, swelling and eeehy- 
moses about the joints, especially the knee and ankle, and extreme 
tenderness and hyperesthesia of the lower extremities. There is 
also cachexia and marked anemia. 

Scurvy in the infant is now recognized as the same disease which 
occurs in the adult, although it is modified by the different chemical 
and biological conditions found in the immature and rapidly develop- 
ing organism of the infant or child. 

The faulty nutrition which causes scorbutus is, in all probability, 
due to4:he lack of some food elements which are essential to normal 
metabolic processes and to growth. The exact nature of these con- 
stituents is not clearly understood, but it is believed that they belong 
to the group of vitamines. 

Etiology. — Age is one of the chief etiologic factors, most of the cases 
being observed in infants between six and eighteen months of age. 
Before the sixth month scurvy is rare, although Kerley reports a case 
in an infant three weeks old. After the second year but few cases 
occur. 

Infants of the middle and upper classes are most liable to this 
disease, and the great majority of cases have been observed in private 
practice; this offers a strong contrast to rickets, which is essentially 
a disease of the poorer classes. Hygienic surroundings have no influ- 
ence on the development of scurvy, and there has been a history of 
previous gastro-intestinal derangement in such a small percentage of 
cases that the state of the alimentary tract seems to bear no relation 
to this disease. 

The theory that it is of microbic origin is not supported by the 
clinical and pathological findings. It has apparently been proven 
that the most important etiological factor in the production of scurvy 
is some error in diet ; but so far no single dietetic error has been demon- 
strated as the sole cause of this disease. Temporary faulty nutrition 
will not cause scurvy; but the malnutrition must be prolonged, and 
investigations seem to indicate that this dietetic error is a lack of 
some essential food element, rather than the presence of some abnormal 
food constituent. 



764 SCURVY 

In common with most other diseases of infancy, scurvy appears 
most frequently in bottle-fed infants, although it does occasionally 
occur in the breast-fed. The cases in breast-fed babies and in those 
fed on raw cow's milk form a very small percentage of the total number 
of cases of scurvy which have been studied, and some investigators 
believe that in these instances the milk which the infants had received 
had undergone some unexplainable chemical or biological change. 

It is maintained that heating the milk removes from it something 
which is necessary for the prevention of scurvy, because of the great 
number of scorbutic children that have been fed on pasteurized, 
sterilized, or condensed milk, in comparison with the few cases of 
scurvy which develop in babies who are given raw milk. 

In further support of the view that foods which are heated tend 
to produce scurvy, it has been demonstrated that many more cases 
of scurvy occur in children who are given sterilized milk than when 
pasteurized milk is used, and that when raw milk is substituted for 
sterilized milk many of these cases recover without further treatment. 

The cooking, or heating, of an infant's food apparently destroys, 
changes chemically, or renders less digestible and assimilable, some 
principle of freshness within it, and results in metabolic disturbances 
which cause scurvy. By far the majority of cases occur when pro- 
prietary foods are given for a prolonged period, whether they are 
prepared with or without milk. 

From these facts it is evident that the heating or cooking of food 
given to infants is of more importance in the production of scurvy 
than the use of, or failure to give any one particular food. The fact 
that scurvy sometimes develops in breast-fed babies and in those 
fed on raw cow's milk would appear to contradict the theory that 
the cooking or heating of the food is responsible for this disease. 

Plantanza's observations show that although scurvy develops 
more frequently in babies fed on heated milk which is not used at 
once than on raw milk, yet the disease does not develop when fresh 
milk is heated and used immediately. Experiments on animals with 
raw and heated milk have failed to throw any light on this phase of 
the subject, for they have been too few to be conclusive. 

The report of the American Pediatric Society's Collective Investi- 
gation of Infantile Scurvy, in 1898, brought out some important 
data with regard to the preceding diet in 379 of the cases. The 
summary of this report is given below. 

Breast milk, in 12 cases, exclusively in 10. 
Raw cow's milk, in 5 cases, exclusively in 4. 
Pasteurized milk, in 20 cases, exclusively in 16. 
Condensed milk, in 60 cases, exclusively in 32. 
Sterilized milk, in 107 cases, exclusively in 68. 
Proprietary infant foods, in 214 cases. 

Morbid Anatomy. — The pathological changes in scurvy are most 
marked in the bones, the bloodvessels, and the blood. Hemorrhages 
may be widespread and multiple, taking place in the skin, mucous 



SYMPTOMS 765 

membranes, serous membranes, internal organs, bone-marrow, and 
between the muscles. The subperiosteal hemorrhages are the most 
striking lesion, and may be very extensive. 

The periosteum of the long bones is thickened and congested, and 
in some cases the hemorrhages break through the periosteum into 
the surrounding tissues, often infiltrating the cellular structures about 
the joints, although the joints themselves usually remain unaffected. 
These hemorrhages are much more common in the lower than in 
the upper extremities, and may appear in any area from the great 
trochanter to the knee, or from the knee to the ankle. 

In the bone itself a rarefaction occurs which may or may not be 
due to intra-osseous extravasations. The diaphyses and epiphyses 
of these bones may separate, causing great deformity, although this 
usually occurs in fatal cases. The lower end of the femur or tibia is 
most frequently affected. The minute changes which take place in 
the bones are much like those seen in rickets, but these changes are 
probably a result of the accompanying rickets rather than lesions of 
scurvy. 

Hemorrhages from the gums are very common in infants whose 
teeth have erupted, and the gums have a spongy appearance. The 
changes in the viscera are not constant, but there may be hemorrhages 
in the pleura, pericardium, and peritoneum. Bronchopneumonia 
and nephritis have been observed in quite a number of cases. Hema- 
turia without inflammatory conditions in the kidneys is common, 
and hemorrhages may take place in the orbit or under the dura. 

The alterations in the bloodvessel walls are, as yet, not under- 
stood; but since it has been shown by the capillary resistance test 
that there is a weakness of the vessel walls in scurvy, and studies 
of the blood have demonstrated that there is no deficiency of thrombin 
or blood platelets, and no excess of antithrombin, it is believed that 
the hemorrhages of scurvy are due to this alteration in the blood- 
vessel walls. 

Symptoms. — There are no characteristic prodromal symptoms in 
scurvy, although a period marked by failing nutrition, irritability, 
and pallor may precede the first characteristic symptom, which is 
usually tenderness of the legs. Occasionally other parts of the body 
are hypersensitive; but in the majority of cases tenderness is first 
noticed in the leg, and this may be so slight that, although the infant 
cries out now and then when it is handled, it is quiet when in its bed. 

This hypersensitiveness is often first noticed when the infant is 
being bathed or when the mother or nurse is changing its napkin; 
at the same time it may be observed that the child holds one or both 
legs still, but moves its arms, At first this tenderness is hard to 
locate, but it subsequently becomes constant and acute in one or 
more particular regions, usually about the knees and ankles, which 
are often swollen, these swellings being fusiform in shape, and due 
to subperiosteal hemorrhage. 

In severe cases the tenderness becomes excessive, and may involve 



766 



SCURVY 



all of the extremities, the affected limbs being rotated outwardly and 
maintained in that position, producing the pseudoparalysis of scurvy, 
which is caused by either the reflex or voluntary tenseness of the 
muscles. In severe cases the disability to move may be due to 
epiphyseal separation. 

When the disease is marked, the sternum may become separated 
from the ribs and sink backward. The ecchymosis about the large 
joints and the fact that the child cries when touched, even when 
lying in its bed, often lead to the belief that it is injured. In advanced 
cases the infant becomes pitifully helpless, and lies perfectly motion- 
less, screaming with apprehension whenever anyone approaches the 
crib, for fear it may be moved. 







Fig. 78. — Scorbutus; same child as shown in x-ray plate. 



While ecchymoses in the skin are not common, there are usually 
changes in the gums and mouth from the beginning of the disease. 
The gums become swollen and purple, and may almost cover the 
teeth, particularly the upper incisors. They bleed when touched, 
and hemorrhages may be spontaneous. Bleeding sometimes takes 
place in the vault of the pharynx and conjunctiva, and blood is fre- 
quently vomited or passed in the urine and feces. The stools are 
rarely normal in severe cases, for there is usually catarrhal colitis. 

These symptoms all come on gradually with irregular intervals 



PLATE IV 




X-ray Plate of Child Shown in Fig. 78. 



1 and 2 show subperiosteal hemorrhages and slight calcification of 
periosteum ; 3, expanded ends of diaphyses ; 4, practically normal 
epiphyses. 



TREATMENT 767 

of apparent improvement, and no change in the child's general 
health may be noted for several weeks; but, sooner or later, evidences 
of malnutrition and anemia appear, and it becomes cachectic and 
emaciated. 

In advanced cases there is usually irregular and inconstant fever, 
often due to complications; and, unless treatment is instituted, all 
of the symptoms grow steadily worse and the case terminates fatally 
in from two to four months by general asthenia, or some intercurrent 
infection or complication. 

Diagnosis. — The diagnosis of scurvy can readily be made by those 
who have previously seen cases of the disease, and once it is suspected 
and its cardinal features looked for, there is but little trouble in recog- 
nizing it. 

The history of an infant crying on being taken up, and a history 
of such feeding as might lead to the development of scurvy, together 
with such symptoms as spongy, swollen, bleeding gums, soreness 
and tenderness of the legs, and swelling about the large joints, should 
leave no doubt in the physician's mind as to the nature of the ailment. 
Further proof can be obtained by immediately placing the child upon 
an antiscorbutic diet. 

Rheumatism is the disease most frequently simulated by cases of 
scurvy; b*ut rheumatism is rare at the age when scurvy is most com- 
mon, in scurvy there is no fever, and the pain is usually confined to 
the legs. 

Poliomyelitis is sometimes suspected because of the pseudoparalysis; 
but acute pains in the limbs are rare, and there are no local inflam- 
matory changes in poliomyelitis, while knee-jerks are absent in polio- 
myelitis, and present in scurvy. 

Among the various other diseases with which scurvy is occasionally 
confounded are joint diseases, malignancy of the bones, spinal caries, 
trauma, and syphilis of the bone; but a carefully taken history and 
thorough examination, followed by the administration of orange 
juice as a therapeutic test, will, as a rule, differentiate between these 
conditions. 

Prognosis. — This is excellent when the disease is recognized early 
and promptly treated. In most cases improvement is noticeable 
in from five to ten days, and complete recovery follows within two 
to three weeks. In neglected cases the prognosis depends upon the 
extent of the pathologic changes, the degree of malnutrition, the age 
of the infant, and the presence or absence of complications. Relapses 
are rare unless there is serious disturbance of the gastro-intestmal 
tract. 

Treatment. — The prophylactic treatment consists in avoiding the 
continued use of any food which may have a tendency to produce 
scurvy, and whenever it is necessary to use such foods to supplement 
them by giving a certain amount of orange juice at stated intervals. 
When scurvy appears, fresh cow's milk should immediately be substi- 



768 SCURVY 

tuted for whatever food is being given, the physician prescribing a 
formula or milk mixture exactly suited to that particular infant. 

This procedure alone will often cure the disease; but since the 
child usually suffers a great deal, fresh fruit juice, which is specific 
for scurvy, should be given at once. Orange juice usually agrees 
with an infant better than any other fruit juice, and from one to four 
ounces may be taken daily. A teaspoonful, slightly sweetened, may 
be given, if necessary, every two hours, preferably an hour or so 
before each feeding. Fresh beef juice and potato juice, as well as 
the juice of fresh vegetables, are also very beneficial especially for 
older children. 

The syrup of the iodide of iron in 5- to 20-drop doses, and cod- 
liver oil J to 1 dram, three times a day, are also beneficial when 
anemia and malnutrition are marked. 

Scorbutic babies are very susceptible to intercurrent infections, 
and should be protected against exposure. They should be handled 
very little, and, if epiphyseal separation has taken place, splints 
should be temporarily applied. 



CHAPTER XXV. 
THE NERVOUS SYSTEM. 

I. INTRODUCTION. 

The central nervous sytem of the newborn is the most immature 
of all the organs of the body. This is true not only in regard to its 
morphology, but its function as well. The brain at birth is relatively 
large, yet its histological structures are poorly developed, and before 
it can functionate as in the adult substantial developmental changes 
are necessary. 

Morphology. — Brain. — The brain at birth is relatively large and 
weighs approximately one-fourth of its ultimate weight. According 
to Ziehen, the weight of the brain at birth in proportion to the total 
weight of the body is 1 :8 or 1 : 7, whereas in the adult it is 1 :42 in the 
male, and 1:40 in the female. 

According to Marchand, the brain weighs at birth 13 oz. (371 Gm.) 
in the male, and 12f oz. (361 Gm.) in the female. It increases 
very rapidly in size and, according to Pfister and Marchand, the 
original weight is doubled by the ninth month, and trebled before 
the end of the third year. Its ultimate weight is reached bet\\ een 
the nineteenth and twentieth years in the male, and sixteenth and 
eighteenth in the female. 

Spinal Cord. — The average weight of the spinal cord of the new- 
born varies between y T to T V of an ounce (3 to 3.4 Gm.) (Pfister), 
y T to J of an ounce (2 to 6 Gm.) (Mies). Like the brain, its weight 
increases rapidly, is doubled by the fifth month, trebled by the end 
of the first year, and quadrupled by the beginning of the third year. 
At birth it is 5 T V inches (14 cm.) long, and very slowly reaches its 
ultimate length of 17 to 17f inches (43 to 45 cm.) (Pfister). 

Histological Structure. — The central nervous system of the newborn 
is composed of immature embryonal tissue and cells which, by further 
growth and proliferation, develop into specific ganglionic cells and 
nerve fibers invested with myelin and neuroglia tissue. The most 
marked structural change is the investment of the nerve fibers with 
myelin. 

According to Peritz, the most important centres necessary for the 
postembryonal life of the infant are first developed; namely, the 
gastro-intestinal and cardiorespiratory centres; next those which 
act as a defence to the body, primarily the sympathetic system and 
the spinal and cranial ganglia. At the same time are developed the 
centres for reflex and automatic instinctive movements (kicking, 
swallowing, sucking). The development of the sense centres follows 
later, then the speech centre and, finally, the higher psychical centres. 
49 



770 THE NERVOUS SYSTEM 

According to Thiemich, the myelinization of the tracts of the cord 
at birth is almost complete except that of the pyramidal tracts; in 
the brain stem and cerebellum numerous tracts are invested with 
myelin, whereas in the cerebral hemispheres but few tracts and centres 
have become myelinized. Pfister, Monakow, and others have demon- 
strated at birth some myelinized fibrse propria? and medium-sized 
association fibers in the sense areas and tracts, in those for general 
sensibility, for the tactile, muscle, olfactory, and visual senses, as 
well as in the motor zone, in the pyramidal tracts, and certain seg- 
ments of the corona radiata. 

Myelinization progresses so rapidly that by the third or fourth 
weeks the long association fibers of the regio Rolando and regio 
calcarina are for the most part provided with myelin. By the end 
of the third month, most of the sense areas have been developed, and 
at the end of the first year the majority of the association fibers have 
been almost completely invested with myelin, whereas many years 
must pass before the tangential and the subcortical association tracts 
reach their full development. 

Peripheral Nerves. — The myelinization of the peripheral nerves, 
according to Thiemich, has progressed but little at birth, and the 
areas developed show marked irregularities, being interrupted by 
areas which have not been myelinized. The development, however, 
progresses rapidly, and is complete by the end of the first year. 

Physiological Development. — From what has been stated of the 
morphology of the central nervous system, it may be supposed that 
its functions likewise are most immature at birth, and only very slowly 
developed. This imperfect development is demonstrated by the 
electrical examination of the central and peripheral nervous system. 
The motor cortex, sensory, and motor peripheral nerves are so slightly 
irritable in the first few months of life that the infant's face is totally 
insensitive to strong electrical stimuli. Imperfect development on 
the part of the nervous system is accompanied by a greater need of 
sleep, about 20 hours daily being required during the first few weeks, 
and 13 to 15 hours by the end of the first year. 

The development of the nervous system, however, is best shown by 
examining the reflexes. The tendon reflexes are present at birth, 
and are exaggerated from the second month to the second year. The 
superficial abdominal reflex is frequently absent at birth, but becomes 
very active in older infants. The Babinski and Oppenheim reflexes are 
present normally up to the sixth or even to the tenth month. The 
winking (optic) reflex appears from the sixth to the eighth week, whereas 
the conjunctival and reflex closure of the eyelids exist at birth and 
are active during the first few months. The pupillary light reflex 
is present at birth, and becomes especially active in the latter part 
of infancy. A reaction to accommodation has been observed by 
Pfister after the fourth week. The aversion to light disappears between 
the tenth and twentieth days. 



INTRODUCTION 111 

Psychological Development. — Little is definitely known in regard 
to the psychical development of the child at birth. Stern thinks 
that, considering the number of tracts partially developed at birth, 
the child possesses a primitive consciousness, but that essentially 
the child is a subcortical being. Its acts are reflex movements brought 
about by stimuli, either from within or without, the centres for which 
are located within the cord and medulla. Thus, the various forms 
of the more vulgar type of sensations, such as thirst, hunger, and 
pain, call forth instinctively certain reflex responses, such as crying, 
sucking, kicking and swallowing, which are the protective vital mani- 
festations of the newborn. 

Sensibility. — In the first few days all sensory areas functionate 
sufficiently to call forth motor responses. The senses of touch, smell, 
and taste are all developed at birth; whereas the two higher senses, 
sight and hearing, are less highly developed. Sight is present in 
its most primitive form. The child reacts to the most extreme bright- 
ness, but has no conception of color, form, position, or distance. At 
about the third or fourth day it will momentarily follow a bright light, 
but will not fix its eyes distinctly upon objects before the fourth or 
fifth week, and not before the third or fourth month will the child 
follow objects, and begin to store up visual memories of what it sees. 

Many infants are deaf at birth; stimuli, however, will call forth 
responses. The child may respond to a sudden noise by twitching the 
body or turning the head. Acoustic memories are gradually stored 
up; so that, by the end of the third month, the child has almost com- 
plete control of all its senses. 

Development of Speech. — The child at first can utter involuntary 
sounds, thus gaining control of the speech mechanism. Gradually 
it learns by hearing to reproduce sounds, at first unconsciously, until 
finally conscious speech is acquired. By practice the child rapidly 
adds to its vocabulary which, according to Ziehen, at eighteen months 
should consist of 40 words, by the end of the second year of 200 to 
300 words. With this rapid increase the child deepens his judgment, 
increases his associations, imitative instincts, his conceptions of 
personality, and gradually so develops that he will speak of himself 
in the first, instead of the third person. 

In studying the morphology of the brain, its rapid increase in size 
within the first three or four years of life is held to be of the greatest 
importance. We now see why this is so. Functional development 
is commensurate with this gross increase for, by the end of the third 
or fourth year, the child is able to respond rudely to all stimuli for 
the sense organs, has its motor functions to a certain extent under 
control, is able to speak, to accomplish simple associations, and has 
a conception of personality (Craemer). We can, therefore, readily 
understand the great increase in brain tissue. 

Peculiarities of the Nervous System of the Child. — Feeble inhibitory 
tone is the most important peculiarity of the child's nervous system. 
The child responds to stimuli with increased reaction which, in the 



772 THE NERVOUS SYSTEM 

adult, would produce no result. This function. of inhibition being 
the last function of the nerve cell to be developed is only imperfectly 
developed, owing to the very extensive areas of the central nervous 
system which are undeveloped. As the child grows older, and its 
nervous system develops, the inhibitory tone increases. According 
to Peritz, this feeble physiological inhibition is shown by the reactions 
of the child. It desires everything it sees; it is afraid of darkness, 
strange faces, and animals; it is easily frightened. Feeble inhibition 
is also observed in the child at play; it runs, jumps, kicks, being 
conscious of no restraint; all these are evidences of a lack of inhibition. 

The lack of inhibitory tone is further shown by the development 
of the child's imitative instinct, as it soon imitates the movements 
of others. It is further shown in the flight of ideas observed in chil- 
dren. In relating stories, or in speaking, they ramble from one thought 
to another, just as these thoughts come to them; this is observed even 
in older children. Lack of tone is also shown by the effect upon the 
cardiorespiratory centre. The increase in heart rate, the variable 
quality of the pulse, and the respiratory changes show a lack of 
inhibitory development. The newborn is sympatheticotonic, not 
vagotonic. 

Feeble inhibitory tone is shown pathologically in the ease with 
which sensory stimuli call forth motor responses. This is most clearly 
exhibited in the ease with which convulsions are produced in chil- 
dren by gastro-intestinal disturbances, intestinal parasites, fever, 
etc. The stimuli from the peripheral nerves are not inhibited, but 
are diffused over the motor cortex, and produce convulsions. Other 
examples are the reflex symptoms due to phimosis, eyestrain, arid 
adenoids. 

Another pathological evidence of feeble inhibition is the frequency 
of irregular muscular movements (choreic, choreiform) in children; 
whereas in the adult these choreiform movements, which are compara- 
tively rare, are associated with definite cerebral lesions, in children 
this is not the case, the athetosis and choreiform movements which 
follow infantile cerebral palsies being independent of any local lesion. 
In the neuroses, the imitative instinct of the child is pathologically 
developed, especially in the monosymptomatic type of hysteria so 
common in children, in which the child imitates the movements of 
others. The sensory stimuli from without spread uninhibited over 
a whole motor cortical area, and evoke a response. The unusual 
development of the imagination so frequently observed in hysteria, 
often leading to lying, illusions, and hallucinations, is another evidence 
of this pathological lack of inhibition of the nervous system. 

II. EXAMINATION OF THE NERVOUS SYSTEM. 

The examination of the nervous system of the child is accomplished 
with considerable difficulty, for children cannot localize definitely 
their symptoms. Owing to fright, the symptoms may be exaggerated 



EXAMINATION OF THE NERVOUS SYSTEM 773 

or falsely localized. The examiner will do well first to gain the con- 
fidence of the child before beginning the examination. Naturally 
all painful tests, such as the electrical, should be made last. It is 
of the greatest importance in every case to take a complete history, 
especially, the family history, before beginning the examination. In 
the general examination of a child much information can be obtained 
merely by inspection; this is also true in the examination of the nervous 
system, the shape, size, and symmetry of the head, the facial expression 
of the mentally defective, a flaccid or spastic paralysis, may all be noted. 

Normal Reflexes. — The tendon reflexes are present at birth, become 
active after a few weeks and remain so until the second year. The 
more common deep tendon reflexes, such as the patellar, Achilles, 
triceps, and biceps are all evoked by holding the limb in such a posi- 
tion as to cause complete relaxation of the muscles, and then giving 
the tendon a sharp blow with a percussion hammer, whereupon the 
response will follow; in the patellar tendon reflex it is extension of 
the leg; in the Achilles, extension of the foot; in the triceps, extension 
of the forearm; and in the biceps, flexion of the forearm. The majority 
of the superficial skin reflexes obtained by irritating the skin do not 
appear at birth. The abdominal is sometimes observed about the 
third day, but is not constant before the fifth month. The cremasteric 
and gluteal reflexes appear at the third month, but are not constant 
before the end of the first year. 

Abnormal Reflexes. — 1. Babinski Reflex. — This reflex is obtained 
by irritating the outer margin of the sole of the foot by drawing 
some blunt object along it. Instead of the normal plantar flexion 
of the great toe, there is extension accompanied by a fan-like abduction 
of the other toes. 

2. Oppenheim Reflex. — This reflex is also accompanied by extension 
of the great toe and other toes, and sometimes the foot as well; it 
is obtained by making firm pressure downward along the inner border 
of the tibia with the thumb or blunt end of a percussion hammer. 
In infants from six to ten months old this extension is a normal 
response, whereas a positive Babinski or Oppenheim reflex after this 
age is indicative of a pathological process — disease of the pyramidal 
tract. 

3. Ankle-clonus. — An ankle-clonus is evoked by semiflexing the 
leg, and flexing the foot abruptly dorsalward, when a to-and-fro 
motion of the foot is produced. 

4. Patollar Clonus. — This is a similar reflex produced by abrupt 
extension of the quadriceps femoris muscle and on pushing the patella 
abruptly downward. Both the ankle- and patellar clonus can be pro- 
duced in very young infants. Per it z observed an ankle-clonus in 
a three-weeks-old infant suffering from meningitis. A pseudo-ankle- 
and patellar clonus can be elicited in neurasthenic and hysterical 
children. Thiemich states that an ankle-clonus can be obtained in 
fevers and irritable children up to one year of age without any 
pathological significance. 



774 THE NERVOUS SYSTEM 

5. Kernig's Sign. — With the patient lying upon his back and the 
thighs flexed, complete extension of the leg at the knee-joint is impos- 
sible owing to spasticity of the flexor muscles. This is indicative of 
meningitis. 

6. Bruidzinski's Sign. — This sign is obtained, after passive flexion 
of the neck, with the patient on his back. The lower extremities 
will be drawn up, there being flexion at both the hip- and knee-joints. 
It is an early sign in meningitis. 

The following are elicited in spasmophilic conditions: 

7. Trousseau's Phenomenon. — This is produced by making pres- 
sure around the arm, best with an elastic band, thereby irritating 
the large nerves, and causing the hand and fingers to assume a tetanic 
position, the characteristic position in tetany 

8. Chvostek's Sign. — This is obtained by gently percussing the 
cheek along the course of the facial nerve, best over Chvostek's 
point, which is midway between the zygomatic arch and the angle of 
the mouth. A clonic contraction of the muscles innervated by the 
facial nerve, the angle of the mouth, nose, eyelid, and forehead, 
follows. If the irritability is greatly increased, this same phenomenon 
can be elicited by stroking the cheeks (Schultz's phenomenon.) 

9. Erb's Phenomenon. — This is electrically increased irritability of 
the nervous system. The CaCC is less than normal, and may appear 
at 0.1 MA. AnOO AnCC both being under 5 MA. CaOC less 
than 5 MA. is pathological. 

Hypotonus. — By hopotonus is meant a condition of the muscles 
in which the normal tension is diminished; consequently greater 
excursions can be made by the extremities at the joints; thus, the legs 
can approximate the face; the heels, the buttocks; and the legs can 
be drawn apart to an angle of 190 degrees. In children up to four 
years of age this hypotonus is normal. 

Sensory Examination. — Sensory examinations are not easily carried 
out in children, especially in those under five years of age, for they 
are not sufficiently intelligent to differentiate between the finer tests. 
Very young children are so sensitive to pin pricks that they begin 
to cry, making further examination useless. Only in children above 
nine years of age can we make sensory tests as in the adult. 

Electrical Examination. — This is carried out the same as in the 
adult; but it requires considerable experience in order not to confuse 
the normal muscular contractions with those due to electrical 
stimuli. 

Reaction of Degeneration. — The typical reaction of degeneration 
consists of a loss of excitability of both nerve and muscle to all faradic 
stimuli, and a loss of excitability of the nerve to all galvanic stimuli; 
whereas, galvanic stimulation of the muscle calls forth an increased 
response, i. e., it reacts to a weaker current, or the contraction is 
changed in a typical manner so that, instead of a quiet, sharp con- 
traction, there is a slow, vermiform, lazy contraction of the muscle. 
AnCC is excited more rapidly and appears before the CCC. This is 



LUMBAR PUNCTURE 775 

the typical reaction of degeneration, and denotes a lesion of either 
the anterior horn cells or the peripheral motor nerves. 

Not infrequently, however, only a partial reaction of degeneration 
will be present, and may appear in various ways. There may be 
only diminished irritability of the nerve to both faradic and galvanic 
stimuli, or galvanic stimulation of the nerve and direct faradic stimu- 
lation of the muscle may cause a slow, lazy, muscular contraction. 
There may be only diminished irritability of the muscle to direct 
faradic stimuli, the contraction being prompt. In these various forms 
the AnCC= CCC or CCC> AnCC instead of ACC> CCC. These 
variations, together with the typical, slow, lazy, vermiform contraction 
of the muscle after direct galvanic stimulation, constitute a reaction 
of degeneration. 

m. LUMBAR PUNCTURE. 

Lumbar puncture, first described by Quincke in 1S92, in the past 
few years has assumed such vast importance in the diagnosis and 
treatment of all nervous and mental diseases that a neurological 
study is no longer complete without a thorough investigation of the 
spina^ fluid. 

Technic. — Puncture must naturally be performed under the best 
surgical technic. Either the sitting or recumbent posture may be 
employed. In the sitting position the trunk is bent forward, the 
head flexed upon the chest, the arms allowed to hang loosely at the 
side. In the recumbent method, which in children is preferable, 
because puncture in the sitting posture is not free from danger to 
the little one, the child is placed upon its side, the knee and thighs 
well flexed, the head and shoulders bent forward, so as to separate 
the intra vertebral spaces as widely as possible. A horizontal line 
is drawn from the crest of one ilium to the other, passing the vertex 
bral column through the spine of the fourth lumbar vertebra. As 
the cord in the child is relatively long, in order not to injure it, the 
puncture should be made between the 4th and 5th lumbar or the 
5th lumbar and 1st sacral vertebra?. One either punctures directly 
in the median line or somewhat to the side, preferably the former. 
The lower level of the upper vertebral spine is located with a finger 
of the left hand, and at this level the instrument is thrust through 
horizontally instead of piercing the centre of the intervertebral space. 
If punctured in the centre, then the needle should be directed upward ; 
if punctured from the side, the direction of the needle should be 
upward, forward, and inward. One can readily tell by the sudden 
lack of resistance to the needle when one has pierced the spinal canal. 
The trocar is now withdrawn, and the fluid allowed to flow. The 
lumen of the needle may be occluded by fibrin or pus, or by the pres- 
sure of the fibers of the cauda equina against it. The former difficulty 
is generally overcome by reinserting the trocar, and in the latter by 
slightly withdrawing the needle. In some cases it may be necessary 



776 THE NERVOUS SYSTEM 

to administer a few whiffs of chloroform or to freeze the skin with 
ethyl chloride. Following the puncture, the child should be kept 
quiet for twenty-four hours. For diagnostic purposes from 5 to 
10 c.c. must be withdrawn. 

Pressure of the Spinal Fluid. — Accurate measurement of the pres- 
sure with water or mercury manometers gives us very little informa- 
tion. A relative idea can be obtained by observing the flow — whether 
drop by drop, or in a constant stream. Generally speaking, the 
pressure is increased in all affections of the meninges, in brain and 
spinal-cord tumors, hydrocephalus, hemorrhages, abscesses, epilepsy, 
and eclampsia. On the other hand, meningitis may be present without 
increased pressure. 

Laboratory Examination. — The normal spinal fluid is as clear as 
water, colorless, alkaline, and of low specific gravity, 1003 to 1007. Its 
composition is as follows: 

Water, 98.74 per cent. Solids, 1.25 per cent. Albumin in the 
form of globulin and albumoses, 0.02 to 0.06 per cent. Dextrose, 
0.4 to 1 per cent. Potassium salts, phosphate, and urea, 0.15 to 0.35 
per cent. 

The laboratory study of the fluid should be pursued along five 
different lines: 

(1) Physical, (2) Chemical, (3) Cytological, (4) Serological, (5) Bac- 
teriological. 

Examination. 

1. Physical. — The spinal fluid is either clear, turbid, opalescent, 
purulent, or bloody. In all the acute types of meningitis, such as- 
the epidemic cerebrospinal, pneumococcic, septic, or influenzal, 
and in brain abscesses, one finds various grades of turbidity from 
a slight degree to purulence, depending upon the acuteness of the 
inflammation. On the other hand, in more chronic types, such as 
tubercular and syphilitic meningitis, the fluid is usually clear. In 
tubercular meningitis, the fluid, although usually clear in the begin- 
ning, may quickly become turbid, according to the degree of inflam- 
mation. In intraventricular hemorrhage, the fluid may be bloody. 

2. Chemical Examination. — Albumin. — Nonne, Ross-Jones, Noguchi, 
Kaplan, and Lange have all described tests for detecting albumin. 
Only Kaplan's will be detailed here. 

Kaplan's Test. — After boiling 5 c.c. of spinal fluid in a test-tube 
1 cm. in diameter, 2 drops of a 5 per cent, butyric acid solution in 
normal saline are added, and it is boiled again. After boiling the 
second time 0.5 c.c. of a supersaturated solution of ammonium sulphate 
is underfloated by means of a pipette. After being allowed to stand 
for twenty minutes, an excess manifests itself in the form of a thick, 
granular cheesy ring at the point of contact. Kaplan gets a relative 
idea of the globulin increase by making tests of different dilutions: 
0.5, 0.4, 0.3, 0.2, 0.1, and by adding distilled water up to 0.5 c.c. to 
the tubes containing less than 0.5 c.c. of spinal fluid. 



LUMBAR PUNCTURE 777 

Dextrose. — The reducing substance is sugar, which is detected 
by means of Fehling's test. 

An increase in globulin generally accompanies any inflammatory 
condition of the meninges, and is also present in spinal cord tumors, 
without cellular increase. 

Fehling's reduction is a normal reaction of the spinal fluid. It 
is also present in the more chronic type of meningeal inflammation 
as juvenile tabes, paresis, cerebrospinal syphilis, and sometimes as 
tubercular meningitis. It is not found in any of the acute forms of 
meningitis. 

3. Cytological Examination. — Normally from one to five lymphocytes 
per c.cm. are present in the spinal fluid. Their study is of the utmost 
importance, inasmuch as there may be pathologically a great increase 
in cellular elements. There are three methods in use for the study of 
these cellular elements: (1) The French method; (2) the Fuchs- 
Rosenthal method; (3) the Alzheimer method. 

The French Method.— This consists in centrifuging 5 c.c. of spinal 
fluid for from 20 to 30 minutes. After pouring off the supernatant 
fluid, the sediment is withdrawn by means of a fine capillary tube, 
placed on a slide, and stained for study. Only a relative idea of the 
cellular increase can be obtained by this method. 

Fuchs- Rosenthal Method. — This consists in counting the cells upon 
a special counting chamber; that is, a modified blood-counting chamber 
whose area consists of 16 sq. mm., and depth 0.5 mm. This is the 
best method for obtaining an accurate estimate of the number of cells. 

Alzheimer Method. — This method is employed for cytological study. 
and consists in embedding in celloidin the sediment obtained by 
centrifuging the spinal fluid, then cutting, mounting, and finally 
staining the sections for study. By this method the finer cytological 
studies can be made. 

In all forms of meningeal irritation and inflammation there is cellu- 
lar increase. Either the lymphocytes or poly nuclear leukocytes 
predominate according to the acuteness of the inflammation. Conse- 
sequently in all acute types of meningitis we have a predominance 
of polynuclear elements; whereas, in the more chronic type — spinal 
syphilis, juvenile tabes, and paresis — the lymphocytes predominate. 
In tubercular meningitis there is generally a lymphocytosis in the 
earlier stages; but subsequently the polymorphonuclear elements 
predominate, frequently forming as high as 90 per cent, of the total 
number of cells. In brain tumor (non-syphilitic), the endarteritic 
type of cerebral syphilis, hydrocephalus, and spinal cord tumors, 
there is a negative cell count. 

4. Serological Examination. — In all neurological cases there should 
be a Wassermann reaction made of the spinal fluid, as well as of the 
blood serum. In cases of paresis, there is generally a positive Wasser- 
mann reaction in both fluid and serum; in tabes, the reaction in the 
fluid is positive in 60 per cent. (Xonne) ; it is generally negative in 
cerebrospinal syphilis (Plaut). 



778 THE NERVOUS SYSTEM 

5. Bacteriological Examination. — Microscopic preparations should be 
made of all spinal fluids in order to examine them for bacteria. 
The Diplococcus intracellularis meningitidis is, as its name signifies, 
an intracellular diplococcus which does not retain the Gram stain. 
Tubercle bacilli are best found by making dry preparations of the 
web-like coagulum of fibrin which usually collects in the test-tube 
after standing for some time. The coagulum is well teased out upon 
a slide, and then stained for the tubercle bacilli. When a coagulum 
does not form the fluid should be centrifuged, so that the bacteria 
will settle in the sediment. It often requires long diligent search 
to find them, and repeated examinations from later punctures may 
have to be made before they are found. Cultures should always be 
made and, whenever in doubt, animal inoculations as well. 

IV. CRANIAL AND CEREBRAL PUNCTURE. 

(Neisser, Pollack, Pfeiffer.) 

This is performed for both therapeutic and diagnostic purposes. 
It is easily done in infants, for the fontanelle membranes can be punc- 
tured without trephining. To avoid the sinus longitudinal superior, 
the needle is thrust 1 to 2 cm. laterally from the sagittal suture 
directly through the fontanelle membrane. The trocar is then with- 
drawn, when, if fluid be present, it will flow out. Clear fluid is indica- 
tive of external hydrocephalus, and bloody fluid of pachymeningitis 
interna hemorrhagica. Should one desire to aspirate the lateral ven- 
tricles, the needle is thrust in a few centimeters farther along in their 
direction. These procedures are made use of in the diagnosis and 
treatment of internal and external hydrocephalus and pachymenin- 
gitis interna hemorrhagica. In older children in whom the sutures 
and fontanelles have closed, the point of entrance must be trephined, 
and the whole procedure carried out under the strictest surgical 
technic. 



DISEASES OF THE SPINAL CORD. 

MALFORMATIONS. 

Malformations of the spinal cord are frequently associated with 
those of the brain, with defects of the skull, and of the vertebral 
column, as well as with malformations in other parts of the body; 
viz., ectopia of the bladder and congenital hernia. Malformations of 
the spinal cord may be grouped as follows: 

1. Amyelia — entire absence of the cord. 

2. Atelomyelia — partial development of the cord. 

3. Diastematomyelia and diplomyelia — the division and redupli- 
cation of the cord. 

4. Heterotopia — the malposition of some of the gray matter. 



MYELITIS 779 

All of these varieties are exceedingly rare, and of little interest. 

5. Spina bifida. — By "spina bifida" is meant all congenital defects 
of the vertebral column, these being most frequently present poste- 
riorly in the vertebral arches, but, more rarely, anteriorly in the body 
of the vertebra. 

According to Marchand, there are two kinds of spina bifida: (1) the 
closed form, spina bifida cystica; and (2) the open form, rachischisis. 

All of these malformations, excepting rachischisis, have been consid- 
ered in Chapter VI on Congenital Malformations (see pages 100-103). 

Rachischisis. — In rachischisis, which may affect either the whole or 
a part of the vertebral column, there is an open fissure which exposes 
the posterior surface of the body of the vertebra together with a part 
of the inner layer of the pia and spinal marrow. At the border of 
the cleft, the skin, fascia, muscles, bone, dura, and pia terminate 
abruptly. In embryonal life the spinal portion of the medullary 
groove remains patent. 

MYELITIS. 

Myelitis, other than acute anterior poliomyelitis and compression 
myelitis, is very rare in childhood. Adults and children react quite 
differently to inflammation of the cord. In the child poliomyelitis is 
the characteristic manifestation, whereas in the adult it is myelitis. 
The other types of myelitis, though rarely seen, are transverse mye- 
litis, Landry's ascending paralysis, and disseminated encephalomye- 
litis. Vascular changes in the cord are also included under this head- 
ing, for anatomically and clinically they cannot be differentiated. 

Myelitis may follow any infectious disease, and may complicate 
a syphilitic or tubercular infection. Certain poisons, such as gas and 
arsenic, are known to produce the disease. Numerous bacteria have 
been isolated from the cord, but none specific. According to Brims, 
the disseminated encephalomyelitis is the most frequent type, the 
transverse myelitis and Landry's ascending paralysis being very rare. 
Disseminated encephalomyelitis and Landry's ascending paralysis are 
described under separate headings. 

Transverse Myelitis. — This disease usually sets in slowly after 
some previous infection, with moderate fever, general malaise, weak- 
ness, pains or paresthesia, loss of appetite, and a slowly developing 
paralysis. On the other hand, the paralysis may develop suddenly, 
as an apoplectiform attack. As a result of the inflammation, there 
are sensory, motor, and trophic disturbances. Of the sensory symp- 
toms there may be either pains — girdle pains — due to irritation of the 
posterior roots, or anesthesia, or paresthesia. 

Motor symptoms may be as follows: (1) Clonic muscular spasms 
from irritation of the anterior roots. (2) A flaccid paralysis at the 
level of the lesion. (3) A spastic paralysis below the level of the 
lesion with exaggerated reflexes, ankle and patellar clonus, an absence 
of muscle atrophy and the reaction of degeneration, with positive 
Oppenheim, Babinski, and Mendel-Bechterew phenomena. 



780 THE NERVOUS SYSTEM 

Of the trophic disturbances there are: (1) Atrophy of the muscles 
at the level of the lesion with an accompanying reaction of degenera- 
tion. (2) Bladder and rectal disturbances with secondary cystitis, 
cystopyelitis, and nephritis. (3) Decubital ulcers. The local symp- 
toms vary according to the location and extent of the lesion. When 
situated in the lumbar portion of the cord, there is a flaccid paralysis 
of the lower extremities, with muscular atrophy, loss of reflexes, loss 
of sensation up to the level of the lesion, girdle sensations at the level, 
sphincter disturbances, and decubital ulcers. 

When the lesion is situated in the thoracic region — its most frequent 
location — there is spastic paralysis involving the lower extremities, 
with exaggerated reflexes, ankle and patellar clonus, Oppenheim and 
Babinski phenomena, anesthesia up to the level of the lesion with 
girdle pains above it, sphincter disturbances, and decubital ulcerations. 
When the lesion is located in the upper thoracic and lower cervical 
regions, there may be a flaccid paralysis of the arms, with loss of 
reflexes, and muscular atrophy with spasticity of the trunk muscles 
and lower extremities. When situated in the upper cervical portion, 
in addition to spastic paralysis of both lower and upper extrem- 
ities, there are oculopupillary disturbances, also interference with 
respiration due to involvement of the phrenic nerve. 

A lesion may be so circumscribed as to give unilateral symptoms, 
leading to monoplegia. The typical Brown-Sequard syndrome may 
be present in rare cases. Occasionally a transverse myelitis may be 
so extensive as to give rise to a complete transverse lesion, in which 
event there is -flaccid paralysis and loss of reflexes below the level of 
the lesion. The symptom-complex may be further complicated by 
the presence of multiple disseminated foci which extend over the whole 
central nervous system. 

Prognosis. — The prognosis is unfavorable. Death is due either to 
involvement of the respiratory centre or to complications, such as 
intercurrent infections, cystitis, or decubital ulcers. However, marked 
improvement and even recovery may take place. This is usually 
observed in disseminated encephalomyelitis. 

Treatment. — During the acute stage the patient should be kept in 
bed, and care taken to prevent bed-sores and cystitis. Electricity 
and all skin irritants are contra-indicated. Warm baths will relieve 
the spasmodic contractions of the muscles. Sedatives, such as sodium 
bromide, must be administered frequently. When convalescence sets 
in the galvanic current should be applied along the spinal column 
and over the atrophied muscles. When the patient begins to regain 
the use of his paralyzed muscles, moderate massage and gymnastic 
exercises should be prescribed, and Frenkel's reeducation movements 
taught. Improvement may follow the administration of potassium 
idodide. In all cases in which syphilis is the etiological factor, anti- 
syphilitic treatment should be instituted at once. In addition, certain 
orthopedic appliances may be necessary. 



CARIES— SPONDYLITIS TUBERCULOSA— POTTS DISEASE 781 

Compression Myelitis.— The spinal cord may be compressed by 
affections which involve the meninges of the cord, such as a tumor, 
or spinal meningitis, or the vertebra* themselves. By far the most 
frequent cause is caries of the vertebrae. Rarer causes are dislocations, 
fractures, tumors, syphilis, arthritis deformans, acute spondylitis 
due to rheumatic fever, osteomyelitis, and typhoid fever. The author 
has recently observed a case of beginning compression myelitis due 
to arthritis deformans in a little girl, six years of age. 

CARIES— SPONDYLITIS TUBERCULOSA— POTT'S DISEASE. 

Etiology. — Myelitis due to caries of the vertebra 3 is a disease of early 
childhood, beginning usually between four and eight years of age. 
It may, however, appear in early infancy, or may be delayed until 
puberty or adolescence. It is usually secondary to, and combined 
with tubercular disease elsewhere in the body, as the lungs, other 
bones, joints, or glands. It may develop spontaneously or following 
traumatism. 

Pathological Anatomy. — Although usually secondary to tuberculosis 
elsewhere in the body, the primary vertebral focus of infection is in 
the body of one or more of the vertebrae. The tubercle bacillus 
causes the formation of spongy granulation tissue which, by disin- 
tegration of the bony tissue, leads to a secretion of thick material 
resembling pus. This may continue until there is complete softening 
of the body of the vertebrae when, on removal of the support, the 
overlying vertebrae sink in, and produce a characteristic angular 
projection of the spinous process — kyphosis. 

Compression of the cord is not usually due directly to compression 
of the vertebrae, but to a narrowing of the spinal canal and compression 
by the thickened dura. The adjacent dura becomes inflamed, both 
as an internal and external pachymeningitis, and becomes greatly 
thickened. The pressure of this tubercular mass upon the cord causes 
edema by interfering with the free flow of blood and lymph, giving rise 
to anemia sufficient to cause different grades of degenerative changes 
in the cord. Generally this mass is located anteriorly, but may sur- 
round the cord. More rarely, sudden compression of the cord is due 
to dislocation of a vertebra. 

The lumbar, dorsal, and cervical vertebrae are most frequently 
involved, in the order mentioned (Schmaus). Compression symp- 
toms are present in 80 per cent, of the cases of the dorsal and cervical 
varieties, but are less common in the lumbar and sacral varieties 
(Schmaus). Microscopic examination shows degeneration of the tracts 
and nerve roots compressed. Following the edema there is swelling 
of the axis cylinder, later degeneration of the nerve fibers. 

Symptomatology. — The symptoms may arise from the side of the 
bones, the nerve roots, or the spinal cord. The earliest symptom 
is pain over the involved vertebrae, this being increased by motion 
or compression. In children pain may be absent; and, as a result, 



782 THE NERVOUS SYSTEM 

in order to produce fixation of the joint, there is reflex muscular con- 
traction. Irritative root symptoms are not so extensive, but form an 
early symptom of the disease, the pain being sharp, lancinating in 
character, and distributed over the course of the affected nerve. The 
paralytic symptoms, the result of compression, depend upon the point 
of compression. 

At first there is muscular weakness; but, as the pressure advances, 
the picture of transverse myelitis develops, differing from the latter 
in that sensory disturbances are much in abeyance. Touch and 
temperature may be affected; pain and muscle sense are usually 
intact. Sphincter disturbances are generally absent until late in 
the course of the disease. As the compression usually affects the 
thoracic region, there follows a spastic paraplegia of the lower extrem- 
ities, with increased reflexes, ankle- and patellar clonus, Oppenheim 
and Babinski phenomena, and anesthesia of varying degree up to 
the level of the compression, where there is an area of hyperes- 
thesia. 

Severe girdle pains may appear as well as sphincter and trophic 
disturbances. (For the symptoms of compression on other parts 
of the cord, see chapter on Myelitis.) When the upper cervical ver- 
tebrae, the atlas, and the axis are involved there is usually marked 
bilateral occipital neuralgia. In addition bulbar palsies are frequent. 
Respiration is also endangered from involvement of the respiratory 
center. 

Diagnosis. — The presence of a deformity, of localized pain, espec- 
ially on percussion over the vertebras, neuralgic girdle pain, rigidity 
of the spinal column, together with any paralysis, usually establishes 
the diagnosis. X-rays and the different tuberculin tests may assist. 
In the earlier stages, before the characteristic picture has been com- 
pleted, since one or more symptoms may be lacking, it must be differ- 
entiated from tumors of the spinal cord and vertebrae, syphilis of 
the vertebrae, spondylitis due to the Bacillus typhosus, or an acute 
osteomyelitis, rickets, or rheumatic fever. Hysteria and neurasthenia 
may also be mistaken for this disease. 

Course and Prognosis. — The course of myelitis due to Pott's disease 
is usually slow and chronic, extending over a number of years. The 
prognosis naturally depends upon the extent of tubercular involve- 
ment in .the rest of the body, and upon the treatment. In many 
cases early symptoms develop long before there is paralysis, and if 
appropriate treatment — i. e., fixation — is begun when the diagnosis 
is made, paralysis may be averted. Under proper fixation the paral- 
ysis which occurs early in the disease quickly passes away. When, 
however, paralysis develops during treatment, the progress is unfavor- 
able. Relapses are frequent in later life, being accompanied by 
palsies, which do not occur in the earlier attacks. 

Gibney's records show recovery in 50 per cent, of his cases, and 
death in 20 per cent., whereas Peritz estimated his at 30 per cent, 
of recoveries and 60 per cent, of deaths. 



LANDRY'S PARALYSIS— ACUTE ASCENDING PARALYSIS 783 

Treatment. — The treatment consists, first, of rest in bed, removal 
of the pressure, and fixation of the spine by proper orthopedic appli- 
ances or by bone transplantation; secondly, in the alleviation of the 
symptoms. Many of these, such as neurotic pains and muscular 
rigidity, are relieved by proper fixation. In addition, sedatives may 
be required. Hot and cold douches, and, when possible, packs applied 
to the spine, promote free circulation in the spinal cord. 

General measures, such as plenty of fresh air, especially sea air, 
forced feeding, the administration of cod-liver oil and general tonics, 
are extremely important. Electricity and treatment with tuberculin 
have been ineffectual. The utmost care should be taken to prevent 
bed-sores. 

LANDRY'S PARALYSIS— ACUTE ASCENDING PARALYSIS. 

' This rare disease was described by Landry in 1S59. Following 
premonitory symptoms, such as general malaise, fever, pain in the 
extremities, and paresthesias, extending over a period of several 
days, paralysis appears in the toes and feet, and within a few hours 
extends over the entire limb. After a brief interval the paralysis 
spreads rapidly upward, involving the muscles of the back, thorax, 
arms, and neck. Deglutition and speech are interfered with, also the 
respiration, as shown by Cheyne-Stokes breathing. Usually there are 
short pauses in the progress before the paralysis is complete. Bulbar 
paralyses do not usually appear, owing to the rapidity of the process; 
although facial and ocular palsies have been reported. Paralysis 
may develop within twenty-four to forty-eight hours, and occasionally 
proves fatal in that time, or it may be two to three weeks reaching 
its maximum. 

The paralysis is always flaccid. The reflexes may be absent, but 
are never exaggerated. Electrical disturbances are not usually 
found. Slight sensory disturbances, such as paresthesia and partial 
anesthesia, are often present. Muscular atrophy, and sphincter and 
trophic disorders do not appear. The consciousness remains clear 
until the end. 

Instead of its usual ^ascending course, the disease may set in with 
bulbar paralysis, then rapidly extend downward over the arms and 
trunk. In this type, death may take place before the legs are involved. 

In its nature the disease is an acute intoxication involving the 
medulla oblongata and spinal cord, and in some cases the spinal roots 
and peripheral nerves. Splenic enlargement is frequently observed. 
It has been described as a clinical form of acute poliomyelitis. The 
disease sometimes follows certain infectious diseases; viz., typhoid 
fever, diphtheria, influenza, anthrax, whooping-cough, and syphilis. 

Pathological Anatomy. — Formerly the pathological findings were 
thought to be negative, but now finer methods of examination show 
a diffuse and disseminated myelitis with changes especially prom- 
inent about the bloodvessels, viz., thrombosis with softening, hemor- 



784 THE NERVOUS SYSTEM 

rhages, and round-cell infiltration leading to changes in the nerve 
fibers, particularly to a swelling of the axis-cylinder. These changes 
are usually diffuse. In other cases, neuritis of the nerve roots and 
peripheral nerves has been observed. Numerous non-specific organ- 
isms have been found in the gray matter of the medulla and cord. 

Diagnosis. — The diagnosis of the malady is usually easy, consider- 
ing the rapidity of its course. Peripheral neuritis, acute poliomye- 
litis, and spinal infantile muscular atrophy must all be differentiated 
from it. . 

Course and Prognosis. — The course of the disease is most frequently 
fatal, death taking place within three to seven days, either from 
asphyxia or secondary aspiration pneumonia. Arrest of the disease 
may, however, be observed at any stage. 

Treatment. — Great care must be exercised to prevent aspiration 
pneumonia. If the patient is not too weak, hot packs should be 
given. Counter-irritation with the cautery has been recommended. 
If syphilis is suspected, mercury should be begun at once. Ergotin, 
also, has been recommended; otherwise the treatment is the same 
as for myelitis. 

ACUTE ANTERIOR POLIOMYELITIS— INFANTILE PARALYSIS. 

Definition. — Acute anterior poliomyelitis is an infectious disease 
of the central nervous system, appearing either epidemically or 
sporadically, usually affecting very young children, and giving rise 
to a flaccid paralysis. This is followed by gradual improvement; 
but, as a rule, some permanent paralysis remains in certain muscles 
which undergo atrophy. 

History. — The best early clinical description of this disease was 
by Heine, in 1840. Medin described it in 1890, and demonstrated 
that it occurred epidemically. Since that date numerous epidemics 
have occurred in this country, Norway, Sweden, France, Italy, 
Austria, Germany, and Australia. Formerly, as the name implies, 
the disease was thought to be one of the anterior horn cells; but since 
the epidemic in Sweden, in 1905, during which Wickmann demonstrated 
various clinical varieties of the disease, our conception of it has been 
broadened, and we now know that the lesion is not confined to the 
spinal cord, but extends to the pons, medulla, midbrain, cerebrum, 
and meninges. 

Wickmann not only described the pathology and epidemiology of 
the disease, but was the first to describe the abortive type of polio- 
myelitis. In 1909, the disease was produced experimentally in mon- 
keys by Flexner and Lewis, Landsteiner and Popper, and by Strauss. 
In the same year, working independently, Flexner and Lewis, Leiner 
and von Wiesner, and Landsteiner and Levadii, reproduced the disease 
in monkeys, transmitting it from one monkey to another. Finally, in 
1913, Flexner and Noguchi cultivated the infecting organism, and have 
since established the fact that it is the cause of the disease. 



ACUTE ANTERIOR POLIOMYELITIS— INFANTILE PARALYSIS 785 

Etiology and Epidemiology. — Numerous epidemics within the past 
decade have materially enriched our knowledge and conception of 
the malady. It is essentially a disease of early childhood, occurring 
most frequently within the first three years of life, although adults 
are occasionally affected. The time of greatest predisposition to it is 
during the latter half of the second year. The following table, in 
part taken from that of Frauenthal and Manning, shows the relative 
age of onset: 



Ages. 


Wickmann, 
Sweden, 

1905. 
Per cent. 


Manning, 
Wisconsin, 

1908. 
Per cent. 


Lovett, 

Massachusetts, 

1909. 

Per cent. 


to 5 years 

6 years and over . 


. . . 40.6 
. . . 59.4 


49.8 
50.2 


71.5 
28.5 


Ages. 


New York City, 

1907. 

Per cent. 


Rockefeller 
Institute, 

1911. 
Per cent. 


Muller, 

Hesse-Nassau. 

Per cent. 


to 5 years 

6 years and over . 


. . . 90.5 
. . . 9.5 


89.0 
11.0 


90.0 
10.0 



Both sexes are equally affected. Epidemics occur, especially during 
the summer months, reaching their maximum in late summer or 
early autumn. The disease predominates in the country rather than 
in the city. It has been known to follow practically all of the acute 
diseases, especially pneumonia and measles, but usually the children 
attacked have previously been perfectly healthy. Other exciting 
factors which have lowered the patient's resistance and made him 
more susceptible to infection have been exposure to cold and damp- 
ness, overexertion, and trauma. One epidemic usually renders a 
community immune. 

The infectious nature of the disease has now been definitely estab- 
lished by the cultivation of the infecting microorganism by Flexner 
and Noguchi, and the experimental production of the disease in mon- 
keys by inoculation of the cultures which had previously passed 
through a number of artificial media for a period of eighteen months. 
The microbic agent, or virus, consists of minute globular bodies which 
are stainable and visible under the high power of the microscope. It 
is a filterable organism, and is resistant to the action of glycerin, 
to freezing, to a 0.5 per cent, solution of carbolic acid, and to ordinary 
degrees of heat. 

Mode of Infection. — From the work of Flexner and Lewis it seems 
well-established that the upper respiratory tract is the port of entrance 
of the disease. The lymphatics of the nasal mucosa which pass out 
with the filaments of the olfactory nerve are directly connected with 
the meninges, and carry the infecting organisms to the spinal fluid. 
The virus is also given off through the nasopharyngeal mucosa. 

There are two diverse views as to the mode of infection: (1) By 
means of the stable fly (Stomoxys calcitrans), as expounded by Rosenau; 
(2) by personal contact. According to Flexner, from the evidence at 
50 



786 THE NERVOUS SYSTEM 

hand the virus is present in the nasal and buccal secretions. Those 
who suffer from the disease transmit it by implanting the virus upon 
the upper nasal mucosa of other susceptible persons who then develop 
an attack. Those who suffer from the abortive type of poliomyelitis 
spread it in the same manner. In addition there are (1) healthy 
carriers who have been in intimate contact with patients; also (2) 
chronic carriers who have recovered from an acute attack but who, 
even after the lapse of several months, are capable of transmitting 
the disease. Moreover, it may be conveyed by certain passive agents, 
such as clothing and dust, also by domestic animals, flies, and insects, 
for the virus is known to be very resistant. 

One infection with poliomyelitis confers an active immunity upon 
the patient. Immune bodies are formed, which are readily demon- 
strated biologically by the neutralization of active virus by the blood 
serum of a patient who has recovered from the disease. This neutral- 
ized virus will not reproduce the disease experimentally in monkeys; 
that is, the active virus has now become absolutely inactive. The 
neutralization test is of the greatest importance in the diagnosis 
of the abortive type of poliomyelitis. 

Pathological Anatomy. — That the virus gains access to the body 
through the upper respiratory passages, and is carried by the lym- 
phatics along the filaments of the olfactory nerve to the cerebrospinal 
fluid, is shown by the earliest pathological changes observed in the 
central nervous system. There is hyperemia, also a mononuclear 
collection of cells in the perivascular lymph spaces of the bloodvessels 
of the pia-arachnoid which communicate with the cerebrospinal fluid. 
This cellular infiltration is conspicuous along the anterior surface of 
the cord, especially about the anterior fissure. The pathological pro- 
cess then extends to the cord and brain by way of the lymph spaces 
of the vessel sheaths as they enter the cord from the meninges. Here 
similar hyperemia and round-cell infiltration take place within the 
perivascular lymph spaces. 

This cellular infiltration, extending along the course of the blood- 
vessels, may partially constrict the lumen and cause extensive edema. 
A few leukocytes may be present in the early stages, but they are 
replaced by lymphocytes, and by glial and proliferating endothelial 
cells. The proliferation and infiltration of cells extends into the 
adjacent tissues in the tissue spaces of the cord and neuroglia. In 
addition, hemorrhages are found, due either to toxic or mechanical 
injury to the intima. 

As a result of these primary vascular changes — cellular infiltration, 
hemorrhages, edema — and the resulting anemia, there is degenera- 
tion of the interstitial tissue and nerve cells. Various degrees of 
degeneration are observed, from simple swelling to complete destruc- 
tion and disintegration, and after this destruction polymorphonuclear 
neurophages enter and ingest the neurotic material. The lumbo- 
sacral and cervical enlargements of the cord are the portions most 
frequently involved. 



ACUTE ANTERIOR POLKJM YELITIS— INFANTILE PARALYSIS 787 

At the same time similar changes are observed in the posterior 
roots, and to a less extent within the brain, pons, and medulla, espec- 
ially about the cranial nerve nuclei, and in the gray matter about the 
fourth ventricle. 

A microscopic cross-section made at this acute stage shows hyper- 
emia, especially about the anterior horn, increase in and dilatation 
of the bloodvessels,' hemorrhages, cellular infiltration of the vessel 
walls and throughout the gray and white matter, and nerve cells in 
different stages of degeneration. The ganglion cells may simply be 
clouded, or the nuclei may be indistinct or may have fallen out, or 
there may be complete disintegration of the cells together with its 
dendrites and axis-cylinder. 

In addition to these acute changes within the central nervous 
system, there is also enlargement of all lymphoid tissue, especially of 
Peyer's patches in the intestines and of the mesenteric lymph glands, 
with cloudy swelling of all parenchymatous organs, such as the liver 
and kidneys. 

Should the inflammation subside when but slight degenerative 
changes have taken place in the nerve cells, complete regeneration 
may follow; but, if continued until there is absolute atrophy, regen- 
eration is no longer possible, and in consequence of the atrophy of 
the cells and neuroglia there is a contraction of the area about the 
anterior horn which is readily disinguished on cross-section. The 
ganglion cells have disappeared, and are replaced by paler glial tissue; 
the vessel walls are thickened; the division between gray and white 
matter is indistinct; and the anterior roots and peripheral nerves 
contain degenerated fibers. The affected muscles exhibit different 
degrees of atrophy, varying in color from salmon to a pinkish, grayish, 
or yellowish hue. 

In extreme cases the muscle fibers have completely disappeared, 
and are replaced by fibrous and adipose tissue. The long bones are 
likewise affected, in that they are usually shorter, and the shafts are 
thinner than the normal ones. The affected joints and ligaments 
are relaxed. The demonstration of such a widespread reaction to 
the virus is wholly in line with recent clinical and epidemiological 
investigations which tend to regard the disease as a general infection 
and a generalized process which affect the parenchymatous organs, 
the lymphoid tissue, and, more especially, the nervous system 
(Peabody, Draper, Dochez.) 

Symptomatology. — The clinical course of poliomyelitis resembles 
that of any other acute infection. We distinguish four periods: (1) 
A period of incubation; (2) a period of prodromal and initial symp- 
toms; (3) a period of paralysis; (4) a period of retrogression. 
Frequently the different periods are not separable. 

Incubation. — The incubation period usually lasts from two to ten 
days, although it may be less than twenty-four hours, or may extend 
to three weeks, according to the virulence of the infection and the 
resistance of the patient. 



788 THE NERVOUS SYSTEM 

The prodromal period is characterized by certain general symp- 
toms which continue from one to three days. Certain symptoms 
predominate in certain epidemics. The disease sets in usually with 
fever which varies between 102° and 106° F., and occasionally with 
a chill; there are general malaise, nausea, vomiting, loss of appetite, 
rapid pulse and respirations, profuse sweating, constipation, and 
retention or suppression of urine. There may be weakness in one or 
more limbs or groups of muscles, and in addition drowsiness, coma 
and delirium, but rarely convulsions. Certain skin affections — herpes, 
erythema, and a scarlatinal-like rash — are sometimes observed. 
Meningitic symptoms may be pronounced. There is rigidity of the 
neck, with irritability of the spinal column, severe pains in the back 
and extremities, hyperesthesia, basilar headache, Kernig's sign, and 
tremors; twitchings and convulsive movements and prostration may 
be marked. 

In certain epidemics gastro-intestinal symptoms, expecially diar- 
rhea, have predominated, while in others the disease has set in with 
bronchitis, or coryza, or with angina which simulated tonsillitis. 

The fever may run to 104° or 106° F., exhibiting slight morning 
remissions, then dropping by degrees to 100° F. before the onset of 
paralysis; it may reach normal several days after paralysis has set 
in. The pulse rate varies between 120 and 200, the respirations 
between 40 and 60. 

In some cases these prodromal symptoms may be so mild as to 
be entirely overlooked, the paralysis coming on overnight in a pre- 
viously healthy child. The diagnosis of the paralytic stage of the 
disease is of the greatest importance; for, if an early diagnosis is made, 
proper measures can be instituted to prevent the spread of the disease, 
and early treatment begun before destruction of the nerve cells has 
taken place. In addition to the general symptoms, the examination 
of the spinal fluid is an important aid to the diagnosis. In the prepara- 
lytic stage the fluid is under moderate pressure, increased in amount, 
clear or opalescent in color. There is cellular increase, of which about 
90 per cent, are polymorphonuclear cells, also a slightly increased 
or normal globulin reaction, with a normal reduction of Fehling's 
solution. On standing, a sterile coagulum may form. 

Paralysis usually sets in several days after the onset. It may either 
appear suddenly — as overnight — or develop more gradually, there 
being first a weakness, paralysis following within several days. The 
paralysis is usually diffuse and progressive, extending from one limb 
to another, and reaching its maximum within several days to one 
week. Characteristic of the paralysis is its unsystematic distribu- 
tion, for all combinations of paralysis of the extremities, trunk, and 
cranial nerves may be found. The following table, taken from the 
work of Frauenthal and Manning, shows the distribution of the 
paralysis, as recorded by Lovett and Sheppard in 1910: 



ACUTE ANTERIOR POLIOMYELITIS— INFANTILE PARALYSIS 789 

Distribution of Early Paralysis. 

Cases. 

One leg only 145 

Both legs 146 

One arm only 44 

Both arms 12 

One arm and leg, same side 50 

One arm and leg, opposite sides 18 

Both legs and one arm 32 

Both arms and one leg 8 

Both arms and both legs 51 

Ataxia (transitory) 7 

Back 79 

Abdomen 38 

Neck 13 

Respiration 39 

Deglutition 12 

Intercostal 1 

Face 7 

Right face 31 

Left face 24 

Strabismus 2 

759 

From the above it is evident that the lower extremities are most 
frequently involved — twice to three times as often as the upper 
extremities. Paralysis of the diaphragm and the muscles of the 
abdomen, back, and neck is not rare. Bulbar palsies are frequently 
observed, the facial and hypoglossal forms, with resulting difficulty 
in deglutition and speech, being the most common. In addition, 
there may be ocular palsies from involvement of the abducens and 
oculomotor nerves. 

In certain cases, such as have been described by Medin, bulbar 
palsies may be the only ones to appear. With the advent of these 
palsies, the prodromal symptoms diminish in intensity, the tempera- 
ture, pulse rate, and respiration suddenly drop, and the gastrointes- 
tinal and bladder disturbances improve, although retention of urine 
may persist when the lumbar segment is affected. On the other hand, 
meningeal symptoms progress until retrogression sets in. 

Whereas, in the beginning, the paralysis is quite extensive, by the 
end of the second week it usually recedes and there is return of func- 
tion. In exceptional cases this may be complete. Usually, cases of 
more or less extensive paralysis recover, except for one or more extrem- 
ities or groups of muscles; then again, there may be no recovery from 
the paralysis. When the paralysis affects the legs, two types are 
distinguished, the upper and lower leg type. In the upper or thigh 
type, the glutei, iliacus, psoas, and antero-external muscles of the 
thigh, especially the quadriceps femoris, are involved; whereas, in 
the lower leg type, the peronei and anterior tibialis are usually the 
ones affected. 

Likewise in the arm; instead of the paralysis being complete, two 
types — upper and lower arm types — are usually recognized. In the 
upper arm type the scapular muscles — the biceps, deltoid, and sup- 



790 THE NERVOUS SYSTEM 

inator longus — are involved; whereas, in the lower arm type, all the 
muscles below the elbow except the supinator longus are affected. 
Complete and permanent paralysis of the four extremities, or of an 
arm, of the diaphragm, back, neck, and intercostal muscles, is rare. 

Permanent paralysis of the abdominal muscles is more common. 
The paralysis is flaccid, and is quickly followed by a diminution in 
the size of the affected parts, with atrophy of the muscles unless the 
paralysis quickly recedes. A reaction of degeneration soon follows. 
In the beginning there is increased irritability to mechanical and 
faradic stimulation, but a loss of reflexes to faradic stimulation of 
both muscle and nerve rapidly develops. The muscle responds to 
galvanic stimulation by a slow vermiform contraction, and the ACO 
CCA. Muscles that respond to faradic stimulation usually recover 
either entirely or in part; whereas muscles which exhibit complete 
reaction of degeneration improve but little, and never wholly recover. 

The deep reflexes of the involved area are absent, but may return 
when the paralysis recedes. If the cervical enlargement be involved, 
there may be spasticity of the lower extremities with increased reflexes, 
ankle and patellar clonus, and positive Babinski and Oppenheim 
phenomena. The skin reflexes are either present or absent over the 
involved areas. Hyperesthesia is frequently apparent at the onset; 
otherwise, there is generally neither sensory nor sphincter disturb- 
ance. This period may continue for several days or several weeks; 
as a rule, improvement follows. Death may result, however, from 
some intercurrent infection or from paralysis of the respiratory centre. 

When the paralysis does not recede, atrophy can be seen at the end 
of the first week, and within six to nine months the affected part 
may be mere skin and bone. In some cases the atrophy is replaced 
by fatty tissue. Muscles which regain their function even as late as 
the sixth to the ninth month show much less atrophy. The reaction 
of degeneration goes hand in hand with the paralysis. Improvement, 
which is usually marked in the first few weeks, may progress throughout 
the first year, after which time the paralysis is generally permanent. 

Trophic disturbances of the skin, tendons, bones, and joints are 
common. The skin of the affected limb is cold and cyanotic; the 
paralyzed limb inhibited in growth. The atrophy of the long bones, 
as well as that of the pelvis, thorax, and spinal vertebrae may be 
detected by the x-rays. The tendons atrophy from disuse. When the 
muscles about a joint are involved, the joint becomes relaxed from 
overstretching of the ligaments and capsule, and results in a looseness 
of the joint which may go on to dislocation. 

Owing to the paralysis, secondary contractures develop early in 
the course of the disease, but are usually not complete until about 
a year and a half after the onset. These contractures are due partially 
to a loss of tone in the paralyzed muscles, but also to a predominance 
of the antagonists. 

If paralysis of an extremity is complete, the paralysis will be a 
completely flaccid one. The most frequent deformities are those of 



ACUTE ANTERIOR POLIOMYELITIS— INFANTILE PARALYSIS 791 

the foot — either pes equino varus, pes valgus, or pes planus. In 
addition there may be a claw-hand (main en griff e), scoliosis, lordosis 
or thoracic asymmetry. 

In addition to the ordinary form of poliomyelitis, the bulbospinal, 
which is an involvement of the lower motor segment, there are 
two other forms which need description: 

1. The cerebral type, associated with a lesion of the upper motor 
segment. 

2. The abortive type. 

Cerebral Type. — Associated with the bulbospinal type of polio- 
myelitis are rare cases of spastic paraplegia with increased reflexes 
and no atrophy, but accompanied by tremor, acute ataxia, athetosis, 
and clouded mentality, due to involvement of the upper motor 
segment, either of the motor cortex or of the conduction paths. Both 
the bulbospinal and cerebral types have been observed in the same 
individual as well as in several members of the same family. 

Abortive Type.— The abortive type of poliomyelitis was first 
described by Wickmann. It is characterized by the usual prodromal 
symptoms. Paralysis does not develop, but in some cases there 
is muscular weakness with a corresponding diminution of reflexes. 
Recovery is rapid. This is a common form of the disease, represent- 
ing from 35 to 50 per cent, of all the cases. As this type is equally 
as contagious as the paralytic type, an accurate diagnosis is of the 
utmost importance; and, in addition to the symptoms, the clinical 
laboratory furnishes valuable assistance in establishing the diagnosis 
from the following points: (1) The spinal fluid shows a cellular increase 
with a predominance of lymphocytes and an increase of globulin; 
(2) the patient's blood serum has the power of neutralizing active 
virus, making it inactive when injected into monkeys; (3) the virus 
detected in the upper respiratory passages will communicate the 
disease to monkeys. The two latter tests are as yet more or less 
impracticable to those who do not have access to an experimental 
laboratory. 

Diagnosis. — The diagnosis of poliomyelitis is usually made without 
difficulty from the facts that its onset is acute, that the character- 
istic prodromal symptoms reach their greatest intensity within a 
few days, and that there is a flaccid atrophic paralysis, with absence 
of sensory, bladder, or rectal disturbances. The diagnosis in the 
preparalytic stage, now of the greatest importance, is usually not 
difficult during epidemics; but, owing to the various aspects of the 
symptoms, may be less readily made at other times. For instance, 
forms of the disease which exhibit marked meningeal symptoms have 
been confounded with cerebrospinal, tubercular, or suppurative 
meningitis, and with meningismus from other acute infections. The 
characteristic findings in spinal fluid examination, in conjunction 
with the clinical symptoms, will usually differentiate the types. 

In poliomyelitis the spinal fluid is under increased pressure, clear 
at the onset, becomes slightly opalescent during the preparalytic 



792 



THE NERVOUS SYSTEM 



stage, and again clears at the height of the paralysis. During the 
preparalytic stage there is a predominance of polymorphonuclear 
cells, quickly changing to a predominance of lymphocytes when 

paralysis appears. There is also 
an increase of globulin, and the 
fluid reduces Fehling's solution. 

Such diseases as tuberculosis of 
the hip-joint, osteomyelitis, rick- 
ets, scurvy, syphilitic pseudo- 
paralysis, Parrot's disease, and 
syphilitic epiphysitis, accompanied 
by fever and pain in an extremity, 
may at times be confounded with 
poliomyelitis; but careful exam- 
ination will usually reveal their 
true nature. Occasionally polio- 
myelitis must be differentiated 
from transverse myelitis and 
peripheral neuritis. Transverse 
myelitis is rare in childhood; it 
is accompanied by anesthesia, 
sphincter involvement, decubital 
ulcers* and spastic paralysis, all 
of which are absent in polio- 
myelitis. Peripheral neuritis, with 
the exception of the diphtheritic 
form, is rare in childhood. Its de- 
velopment is slower, usually step 
by step, the paralysis is more 
symmetrical, and is accompanied 
by sensory disturbances. 

Acute cerebral palsies are dis- 
tinguished by the hypertonia 
present, the increased reflexes, 
the absence of a reaction of de- 
generation, convulsions, athetoid 
movements, and involvement of 
the intellect. 

Birth palsies with flaccid par- 
alysis, usually involving an arm 
and present at birth, may at times be confounded with poliomyelitis. 
Myotonia congenita may be distinguished by the absence of muscular 
atrophy and the absence of a reaction of degeneration. Hysterical 
monoplegias may exhibit atrophy, but the electrical reactions are 
normal. 

Prognosis. — The death rate of epidemic poliomyelitis, variously 
estimated according to age and area of involvement, is between 15 
and 24 per cent. In early infancy, adolescence, and adult life the 




Ftg. 79. — Patient five years, four 
months old; had anterior poliomyelitis 
at the age of twenty-three months; 
shows wasting and shortening of right 
leg. 



ACUTE ANTERIOR POLIOMYELITIS— INFANTILE PARALYSIS 793 

mortality is greater than in early childhood. As the area of cord 
involvement becomes more extensive, and bulbar symptoms develop 
from involvement of the respiratory centre, the prognosis becomes 
more grave. In fatal cases, death usually takes place within eight 
days following the onset, and children should not be declared out 
of danger before that time. The prognosis in the various stages — 
the preparalytic, progressive, and retrogressive — can be made by 
examination of the spinal fluid, which, as has been stated, is clear 
at the onset, opalescent in the preparalytic stage, and clears at the 
height of the paralytic stage. 

In regard to the paralysis, spontaneous recoveries are frequent 
in the mild paralytic cases, being estimated by Frauenthal and Man- 
ning at 16 per cent., and by Zappert at 13.7 per cent. In about 80 
per cent, of the cases, improvement takes place up to a certain point, 
and then the paralysis remains stationary. Under proper treatment, 
however, further improvement may take place in cases which have 
remained stationary for a considerable period; for partial recovery, 
together with return of response to faradic stimulation, has been 
recorded in muscles paralyzed for one to one and one-half years. 
After this period improvement is rare because of the contractures 
which have occurred by this time. 

Prophylaxis. — Since all evidence favors the personal communica- 
tion of the disease, measures adopted to prevent the spread of con- 
tagion should be carried out along these lines. A rigid quarantine 
should be established, and last from four to eight weeks. Children 
who have been exposed should also be isolated, and kept from other 
children, churches, schools, and public gatherings. For a short time 
uro tropin should be administered. As the virus is excreted in the 
nasopharyngeal secretions, all of these should be disinfected and 
prevented from drying, since desiccation does not destroy the virus. 
In addition to the ordinary methods, a nasal spray of 0.5 per cent, 
of menthol, and a mouth wash of 1 per cent, of hydrogen peroxide 
should be used for several days. The urine, feces, clothing, and all 
linens used should be carefully disinfected. The attending physician 
and nurse should likewise take the utmost precautions to prevent 
the spread of the disease. 

In addition there are also chronic carriers of the disease who are 
healthy, which further complicates the problem of prophylaxis. 
Healthy carriers are those who have come into intimate contact with 
a patient; as, for instance, the parents. 

Treatment. — During the acute stage, and immediately after the 
diagnosis has been made, treatment should be begun. There should 
be absolute rest in bed in a comfortable position. An attempt should 
be made to eliminate the toxins from the body; (1) by forcing the 
drinking of water; (2) by an initial cathartic of calomel followed by 
magnesia; (3) by repeated colonic irrigations and gastric lavage; 
(4) by hot packs, or hot air, and electric baths. For the pain hot 
baths should be given for fifteen minutes, at a temperature varying 



794 THE NERVOUS SYSTEM 

between 100° and 103° F., the temperature being gradually increased 
several degrees. An ice-bag should be applied to the head and spine, 
and the temperature controlled by cold sponging. All forms of 
counter-irritation are strongly contraindicated, as is also the use of 
antipyrin and ergot which were formerly resorted to. 

Urotropin, 2 grains, every three hours, may be given for four or 
five days, as well as quinine sulphate for its marked antiseptic prop- 
erties. Frauenthal advocates the use of tincture of echinacea, 5 
minims to 1 dram every six hours, as an internal antiseptic. 

Pain, either spontaneous or from passive motion, is an annoying 
symptom in this early stage, and demands treatment. Simple 
methods^ such as removing the weight of the bed clothes from the 
affected limb, splinting, hot water or hot sand-bags, an electrical pad, 
or wrapping the limb in cotton-wool or blankets, will usually give 
relief. When these methods fail, lumbar puncture is often beneficial, 
and sodium bromide, grains 5, may be given to young children. In 
older patients, aspirin, codeine, phenacetin, and, occasionally, morphine 
may be necessary. 

After the acute stage has subsided and retrogression has set in, 
we should aim to preserve the nutrition and function of the paralyzed 
limbs and prevent contractures by the use of massage, electricity, 
and hydrotherapy. 

Careful massage, twice daily, should be begun as soon as the pain 
has subsided, and passive movements at the same time instituted. 
As soon as voluntary motion returns in the slightest degree, active 
reeducation movements should be taught. Passive movements can 
be carried out during the giving of hot baths. Active movements 
should be encouraged as much as possible. 

Electrical treatment should be begun early, as it is the most 
valuable form of treatment. Frauenthal advises the use of the sinus- 
oidal current, alternating every second day with a combined galvanic 
and faradic current. He recommends that the electrodes be placed 
over the origin and the insertion of the muscles. In the beginning 
the current must be mild, and gradually increased in strength; it 
should be kept up indefinitely, as it prevents muscular atrophy. 

Since contractures develop early in the course of the disease, they 
should be guarded against during the acute stage by the use of sand 
bags or splints loosely applied so as not to interfere with any motion 
or nutrition of the extremity. When no deformity exists, a supportive 
apparatus, such as a walking chair, should be used. 

In the chronic stage with loose joints, an apparatus should be 
employed to fix the joints, as well as mechanical appliances for the 
contractures. In addition to numerous useful mechanical appliances 
there are certain surgical procedures which should always be con- 
sidered, such as shortening and lengthening of the tendons, trans- 
plantation of tendons and muscles, insertion of artificial tendons and 
ligaments, joint stiffening, and, finally, nerve transplantation and 
nerve grafting. 



PROGRESSIVE MUSCULAR ATROPHY 7% 

PROGRESSIVE MUSCULAR ATROPHY. 

Formerly two distinct groups of muscle atrophy were distinguished ; 
namely, the spinal, or neurogenous type, and the myogenous type, or 
muscular dystrophy. 

This simple classification sufficed but a short time, for clinicians 
such as Charcot, Marie, Tooth, and Hoffman observed cases which 
maintain an intermediary and transitional position between these 
two forms, exhibiting symptoms of both types. At the present time 
we distinguish in children the following forms: 

I. Progressive muscular atrophy. 

A. Early infantile spinal progressive muscular atrophy 

(Werdnig, Hoffman). 

B. Progressive muscular atrophy, adult type (Aran, 

Duchenne) . 

C. Amyotrophic lateral sclerosis. 

II. Neural Form of Progressive Muscular Atrophy (Charcot, 

Marie, Tooth, Hoffman). 
III. Muscular Dystrophy. 

Early Infantile Spinal Progressive Muscular Atrophy (Werdnig, 
Hoffman). — This type of progressive muscular atrophy was discoverd 
by Werdnig in 1891, and reported by Hoffman in 1893. It is essen- 
tially a family disease, several members of a family being usually 
affected. It is rarely hereditary, although Hoffman observed it in 
several generations of one family. Isolated cases have been described. 
It is a very rare disease, as only 30 cases have been collected from 
the literature. 

Pathological Anatomy. — There is degeneration of the anterior horn 
cells, motor roots, and nerves, with resulting marked atrophy of 
muscles; sometimes there is secondary fatty degeneration of muscle 
fibers , — lipo matos is inte rstit ia I is . 

Prognosis. — The course is a rapid and progressive one, death usually 
taking place within one to four years either from paralysis of respira- 
tion or some intercurrent infection. 

Symptomatology. — The disease is one of early childhood, usually 
appearing within the first year of life, and affecting hitherto healthy 
children. It is characterized by progressive weakness, which affects 
both sides symmetrically, first appearing in the proximal group of 
muscles. The muscles about the pelvis and thigh, the glutei, ilio- 
psoas, and quadriceps femoris, are first involved, then it extends 
upward and involves the muscles of the back, neck, shoulder-girdle, 
and upper arm — the deltoid, serrati, rhomboids, supraspinalis and 
infraspinatus, the biceps and triceps. Finally, as the disease pro- 
gresses, the muscles of the forearm, the legs, and the smaller muscles 
of the hands and feet are attacked. The muscles of the calf are affected 
late in the disease. Even in well advanced cases the distal muscles 
of the extremities are but little involved. 

Paralysis and atrophy of the affected muscles quickly follow. 



796 THE NERVOUS SYSTEM 

Atrophy about the calves and glutei is frequently masked by an 
excessive deposition of fat between the degenerated muscle fibers, 
the so-called pseudohypertrophy. Deformities of the body, hands, 
and feet are observed, and extreme scoliosis may be present. There 
is talipes equinus varus; the fingers and toes may be claw-shaped 
(main en griff e). Fibrillary twitchings are variable. There are no 
sensory disturbances. The deep reflexes are absent, the plantar 
response is normal. Electrical changes — that is, either partial or 
complete reaction of degeneration — are demonstrable. The cranial 
nerves usually escape. All organs of sense, speech development, 
intelligence, and sphincter control, remain unaffected. 




Fig. 80. — Progressive muscular atrophy (main en griff e). 

Diagnosis. — In cases exhibiting the characteristic symptoms and 
course, the diagnosis is easy. The disease may sometimes be con- 
founded with the neural form of muscular atrophies, the myopathies, 
poliomyelitis, and myotonia congenita (Oppenheim). 

Treatment. — No known treatment influences the course of the 
disease. 

Progressive Muscular Atrophy, Adult Form (Aran, Duchenne). — This 
form rarely occurs except in older children, but when observed it is 
the same as in the adult. The feature which most clearly distinguishes 
it from the usual form in children is that, in this adult type, heredity 
plays no role, also that the disease usually begins in the distal portion 
of the extremities about the small muscles of the hands and feet. 

Amyotrophic Lateral Sclerosis (Charcot). — This form rarely occurs 
in children, and its existence was even denied until Keehn and Naif 
demonstrated it pathologically. It is a hereditary family disease, 
but isolated cases have been observed. The age of onset varies from 
early childhood to puberty. 



NEURAL FORM OF PROGRESSIVE MUSCULAR ATROPHY 797 

Pathological Anatomy. — Among the findings is sclerosis of the lateral 
tracts of the cord, involving the direct pyramidal and Gower's tracts, 
together with atrophy of the anterior horn cells and the nuclei of 
the medulla. 

Symptomatology. — The disease sets in with weakness in the muscles 
of the extremities, and difficulty in walking, the legs being stiff, and 
the child compelled to walk upon its toes. Other cases begin with 
bulbar symptoms — difficulty in chewing, swallowing, and speaking. 
Contractures of the arms and legs develop early. The deep reflexes 
are greatly exaggerated. Oppenheim and Babinski phenomena and 
both ankle and patellar clonus are present. At the same time there 
is atrophy of the small muscles of the hands. The reaction of degen- 
eration is obtained in the affected muscles, and there are fibrillary 
twitchings, but no sensory, sphincter, or pupillary changes. Mental 
development is frequently defective. 

Course. — The course of the disease is usually rapid and progressive ; 
although it may remain stationary for a time, it is always fatal. 

Diagnosis. — Progressive muscular atrophy in the adult must be 
differentiated from spastic paraplegia and diphtheritic paralysis. 
The combination of flaccid and spastic symptoms tends to clear 
the diagnosis. 

Treatment. — Any treatment is unsatisfactory. Systematic massage 
and warm baths should be tried. Electricitv benefits but little. 



THE NEURAL FORM OF PROGRESSIVE MUSCULAR ATROPHY, 

PERONEAL TYPE. 

(Charcot, Marie, Tooth, Hoffman.) 

This type was described by Eulenburg in 1S5G, by Charcot and 
Marie in 1886, and in the same year by Tooth. Later, in 1889, it 
was also described by Hoffman. 

Etiology. — It is essentially a hereditary family disease, observed 
in some cases through four or five successive generations. Boys are 
affected more frequently than girls. The age of onset usually extends 
from early childhood to adolescence. 

Pathological Anatomy. — There are spinal and peripheral changes. 
There are degenerative changes in the posterior columns of the cord, 
in some of the anterior horn cells, in the anterior and posterior roots, 
and in the peripheral nerves. 

Symptomatology. — In the neural form of progressive muscular 
atrophy the involvement of the distal portion of the extremities is 
characteristic. Muscular weakness and atrophy usually begin sym- 
metrically in the peroneal group of muscles and the smaller muscles 
of the feet, causing a foot-drop in walking, the so-called characteristic 
" steppage gait." The muscles of the calf are as yet well preserved. 
The disease may remain stationary for from one to four years, and 
then may extend to the upper extremities, involving the smaller 



798 THE NERVOUS SYSTEM 

muscles of the hands, the extensors of the forearm, and the extensors 
of the fingers and hand. In some cases the disease may spread out 
over the proximal portions of the extremities, involving the thigh, 
pelvic girdle, the fore and upper arms, shoulder-girdle and back. 

Pseudomuscular hypertrophies are not present. Fibrillary twitch- 
ings are frequently observed. The Achilles reflex is always absent 
and the other deep reflexes are either diminished or abolished, depend- 
ing upon the amount of atrophy. Sensory disturbances, such as 
pain, hyperesthesia, anesthesia, analgesia, and vasomotor disturb- 
ances, are common. Complete or partial reaction of degeneration 
is present. Diminished excitability may also be observed in muscles 
apparently normal. Sphincter disturbances do not occur. Secondary 
contractures are common. Club-foot (pes varus), or equino varus, and 
clawed hands and feet are common. 

Prognosis. — The disease is a slowly progressive one, extending over 
a number of years. It may be arrested at different stages, but exacer- 
bations occur. Death usually is due to some intercurrent infection. 

Diagnosis. — This form must be differentiated from the other forms 
of progressive muscular atrophy and dystrophy, and from multiple 
neuritis; but, when characteristically developed, the diagnosis is 
usually not difficult. 

Treatment. — The treatment is only symptomatic. General hygienic 
and dietetic measures, massage, and galvanism should be employed. 
For the contractures, tenotomy and orthopedic appliances are 
necessary. 

PROGRESSIVE MUSCULAR DYSTROPHY. 

A characteristic feature of the myopathies and the dystrophies 
is that anatomically the primary affection appears in the muscles, 
and that the spinal cord and the peripheral nerves escape. Clinically 
we distinguish four different types of dystrophy, as demonstrated 
by Erb, but they cannot always be clearly differentiated. They are 
as follows: 

I. Pseudohypertrophic type (Duchenne). 
II. Juvenile type: Scapulohumeral (Erb). 

III. Infantile type: Facies-scapulohumeral (Landouzy, Dejerine). 

IV. Simple atrophic type: Hereditary (Erb, Leyden, Moebius). 
Etiology. — This is a true, endogenous, hereditary, family disease, 

which may occur in several members of the same family throughout 
several generations. It is usually transmitted through the mother, 
she, herself, being rarely affected. Trauma, infections, and inan- 
ition may be accessory etiological factors. The age of onset varies 
considerably in the different varieties; it may occur at any time from 
early infancy to puberty, or may be delayed until adolescence has 
set in. 

Pseudohypertrophic Type (Duchenne). — The usual age of onset is 
between two and seven years, and the disease develops slowly. The 
child may be late in learning to walk, At first there is awkwardness 



PROGRESSIVE MUSCULAR DYSTROPHY 



799 



in gait, also muscular weakness which is shown by the ease with which 
the child falls, and by the difficulty in rising. This type is character- 
ized by atrophy and hypertrophy of the proximal group of muscles, 
with a predilection for certain groups; thus, the long muscles of the 
back or the abdominal muscles may be involved first. The muscles 
about the pelvic girdle and thigh, the glutei and anterior muscles 
of the thigh, the adductors, and then the flexor cruris, are involved. 
Later the muscles of the calf, the dorsal flexors of the foot, and, as 




Fig. 81. — Pseudohypertrophic muscular paralysis. Boy is climbing up upon his legs. 

the disease progresses, the muscles about the shoulder-girdle and 
upper arm become affected. There is also a tendency to hypertrophy 
of certain muscles; thus, in the lower extremity the gluteus, sartorius, 
and muscles of the calf; in the upper extremity the deltoid, infra- 
spinatus, supraspinatus, and, sometimes, the triceps show beginning 
hypertrophy. The distal portion of the extremities is usually not 
involved. All this forms a characteristic picture. 

Paralysis of the muscles of the back produces lordosis with prom- 
inent and protruding abdomen, and compels the child to throw its 
shoulders back and also to hold the head and trunk erect in order to 
maintain its equilibrium. Thus, a plumb-line, dropped from the 
scapula, falls behind the buttocks. The child's power of locomotion 
is greatly impaired. 

There is a characteristic waddling gait, like that of a goose, or of 
a child suffering from congenital hip disease. The trunk is swayed 



800 



THE NERVOUS SYSTEM 



from side to side in order to get the centre of gravity over the hip- 
joints, and, also, because of the difficulty in raising the thighs. 

The manner of rising from the floor is almost pathognomonic. 
The child first rolls over on his face and abdomen, draws his legs up 
under him, and extends his legs on the thighs. He then brings his 
hands near the feet, and, in order to elevate the trunk, he climbs up 
upon his legs with his hands; finally, by giving his head a swing, the 




Fig. 82. — Pseudohypertrophic muscular paralysis, showing lordosis in the erect posture. 



shoulders are thrown back, and his equilibrium is attained. In addi- 
tion, there is difficulty in mounting stairs. 

Another characteristic sign is the loose-winged scapula. For 
instance, if one attempts to raise the child after pressing his shoulders 
against his sides he "falls through" to his ears. 

Certain contractures appear. There is a pes equinus, from contrac- 
tion of the muscles of the calf. Contractures of the elbow- and knee- 
joints also develop. The mentality is, as a rule, normally developed, 



PROGRESSIVE MUSCULAR DYSTROPHY 801 

although a number of cases have been reported which were associated 
with idiocy and epilepsy. Fibrillary twitchings and the reaction 
of degeneration rarely occur. The deep reflexes are present, and the 
plantar response and sensation are normal. There are no sphincter 
disturbances. 

Juvenile Type, Scapulohumeral (Erb). — The type described by 
Erb begins late in childhood, and is characterized by atrophy, begin- 
ning about the shoulder-girdle. Some muscles are hypertrophied, 
while others are atrophied. Later, the muscles of the upper arm, then 
those of the back- (with resulting lordosis), finally those about the 
pelvic girdle, the thigh and calf, and peronii muscles (with resulting 
talipes equinus), are involved. 

Infantile Type, Facie s-scapulohumeral (Landouzy, Dejerine). — This 
form begins within the first few months of life, affecting male and 
female babies equally, and involving the muscles of the face, espec- 
ially the sphincters of the eyes and mouth. There follows a lack of 
facial expression — a mask-like appearance, with inability to raise 
the eyebrows, close the eyes, or puff out the cheeks. At the same time 
there may be involvement of the shoulder-girdle, or this may be the 
only symptom of the disease for years, after which the process may 
extend to the shoulders, thighs, and pelvis. 

Simple Atrophic Type, Hereditary (Erb, Leyden, Moebius). — This 
form exhibits an unusual hereditary character, with no muscular 
hypertrophy. 

These different forms are mere varieties of the disease, and all 
possible combinations of them may exist in the same individual. 

Pathological Anatomy. — The pathological changes are similar in 
all the forms. The changes are essentially primary in the muscles, 
for none occur in the central nervous system. There is atrophy of 
most of the muscle fibers, with fatty degeneration, fatty and connec- 
tive-tissue infiltration between the individual muscle fibers, and true 
hypertrophy of other muscle cells. On microscopic section, the 
striations of the muscle fibers have disappeared, the fibers are of 
different sizes, some large and other small, and they show fatty degen- 
eration, vacuolation, and a contraction of the muscle fibers. Outside 
the sarcolemma sheath, there is deposited fat and connective tissue, 
showing numerous connective-tissue nuclei. The fat later becomes 
absorbed, and the connective tissue contracts, the atrophied muscle 
being finally replaced by contracted fibrous tissue. There is also true 
hypertrophy of other muscle fibers. 

Diagnosis. — When fully developed, the diagnosis of this disease 
usually presents no great difficulty. It must be differentiated, how- 
ever, from the different forms of muscular atrophy. As these two types 
are the antitheses of one another, it must be borne in mind that 
there are transitional forms which exhibit in part neurogenic, in part 
myogenic symptoms. At times, syringomyelia, diphtheritic paralysis, 
and beginning spondylitis may be confounded with progressive mus- 
cular dystrophy. 
51 



802 THE NERVOUS SYSTEM 

Prognosis. — The course of the disease is slow but progressive, extend- 
ing over a number of years before the patient becomes bed-ridden 
unless death supervenes as the result of some intercurrent infection. 
The disease may remain stationary for a number of years; even 
recoveries from the juvenile type have been reported by Erb. The 
most unfavorable forms are those which begin in early childhood and 
are of the pseudohypertrophic type. 

Treatment.— No treatment is effectual. Organic extracts of the 
thyroid, thymus, and pituitary glands have been tried, also injections 
of fibrolysin. Hygienic measures, such as fresh air, nourishing food, 
and gymnastic exercises, with moderate massage, and electricity, 
especially galvanism, to both affected and unaffected muscles, should 
be prescribed. Tenotomy and tendon transplantation may be neces- 
sary for the contractures, and orthopedic appliances to give support 
to the partially degenerated muscles. 

MYOTONIA CONGENITA (THOMSEN'S DISEASE). 

This rare disease is hereditary, occurs in several members of the 
same family, and is usually congenital. Boys are more frequently 
affected than girls. 

Pathological Anatomy. — Schiefferdecker demonstrated hypertrophy 
of the muscle fibers, an increase in nuclei arranged in rows, and 
granulation of the sar ooplasm. 

Symptomatology.— The chief symptom of the disease is a slow 
muscular contraction or myotonic spasm when voluntary movements 
are attempted. This tonic spasm may last from five seconds to half a 
minute and then relax, allowing the normal movements to be carried 
out. Different groups of muscles may be thus affected; but the 
muscles most frequently involved are those of the extremities, the 
legs more often than the arms. Next in order of frequency are the 
trunk muscles, finally those innervated by the cranial nerves, the 
sphincters of the eye, the masticators, the esophageal, and laryngeal 
muscles. Hence the infant may have difficulty when it attempts 
to nurse, older children on attempting to walk, the patient's feet 
being glued to the ground, also on shaking hands, the child not being 
able to let go until relaxation is complete. Fright and cold increase 
the spasm, whereas heat and alcohol relax it. 

The disease is not apt to be recognized in early infancy and child- 
hood, except in familial cases. The general appearance of the patient 
indicates a good athletic physique, although the strength is subnormal. 

On examination we find two characteristic signs: 

I. The muscles show an increased irritability to mechanical 
stimuli. At the point of stimulation there appears a localized swelling, 
due to muscular contractions, persisting from ten to fourteen seconds, 
and then gradually relaxing. 

II. There is also increased irritability of the muscles to electrical 
stimuli. Mild faradic currents induce a muscle spasm, which persists 



S YRINGOM YE LI A 803 

for a number of seconds after the current is cut off. Direct galvanic 
currents give rise to a reaction similar to the reaction of degeneration. 
This is Erb's myotonic reaction. There are no sensory or sphincter 
disturbances. 

Diagnosis. — The condition should be differentiated from tetany. 

Prognosis. — The affection is not fatal, but persists through life. 

Treatment. — Massage and gymnastic exercises should be prescribed. 
Organic extracts have been tried, but without results. 

MYOTONIA CONGENITA (OPPENHEIM). 

This disease was described by Oppenheim in 1900. As its name 
implies, it is congenital, and is, usually observed in the first few days 
of life. It is characterized by a congenital muscular weakness, usually 
a bilateral symmetrical flaccidity, which affects most frequently the 
lower extremities, less often the upper. The children lie motionless, 
unable to move their legs. Hypotonus is extreme, and the limbs 
will remain in any position in which they are placed. The neck, 
diaphragm, and facial muscles usually escape. There is no muscular 
atrophy. The deep reflexes — the knee-jerk and Achilles reflex — 
are greatly diminished or absent. The electrical irritability of the 
muscles is also diminished or absent, but the reaction of degeneration 
is not observed. There are no sensdry or sphincter disturbances. 
The mentality is normally developed. 

Pathological Anatomy. — Partial degenerative changes in the anterior 
horn cells and muscle fibers have been described, but these patho- 
logical changes are by no means uniform. Rothmann considers the 
disease a form of the early infantile type of muscular atrophy 
(Werdnig, Hoffman). 

Prognosis and Treatment.— Recovery is possible, but the course 
is slow, and the majority of the children affected die from some inter- 
current infection. Systematic massage and electrical treatment 
should be instituted, and the organic extracts, especially thyroidin, 
given a trial. 

SYRINGOMYELIA. 

Up to the age of puberty this disease is exceedingly rare, even its 
existence having been disputed. It is closely related to congenital 
malformations of the central nervous system, and has been described 
as accompanying hydrocephalus, spina bifida, meningocele, syringo- 
myelocele, and reduplication of the cord. In some children the 
affection has an hereditary character. 

Pathological Anatomy. — A cavity forms in the cord, being more 
frequently due to the disintegration of a previously formed mass of 
gliomatous cells which had infiltrated the normal tissue. This infil- 
tration begins near the central canal and, as degeneration progresses, 
the cavity invades the surrounding spinal marrow, the posterior 
horns, posterior columns, and the anterior horns. The cavity is usually 
irregular in outline and varies in size. 



804 THE NERVOUS SYSTEM 

Symptomatology. — The symptoms of this disease are essentially 
the same as in the adult. There is progressive muscular atrophy of 
the upper extremities from involvement of the anterior horn cells, 
and an accompanying spastic paraplegia of the lower limbs from 
involvement of the pyramidal tract. 

The sensory disturbances are very characteristic. There is loss of 
pain sense and temperature sense on the same side as the lesion, while 
muscle sense and the sense of touch may be preserved. In addition, 
there are vasomotor and trophic disturbances of the skin and nails, 
hyperemia, anemia, bullous eruptions, ulcerations, abscesses, especially 
upon the fingers (Mowan's type), and arthropathies. Secondary con- 
tractures, claw-hand (main en griff e), and kyphoscoliosis are also 
observed. The symptoms naturally depend upon the position and 
extent of the lesion. Bulbar symptoms may be present. 

Prognosis and Treatment. — The course of the disease is slow but 
progressive, and is uninfluenced by any known treatment. 

HEREDITARY ATAXIA (FRIEDREICH'S ATAXIA)— HEREDITARY 
CEREBELLAR ATAXIA (MARIE). 

We distinguish two distinct types of hereditary ataxia: (1) the clas- 
sical spinal type, described by .Friedreich in 1861 ; and (2) the cerebellar 
type described by Marie in 1893, known as hereditary cerebellar 
ataxia. Today these two types are considered to be merely two forms 
of the same disease, although clinically and anatomically they may 
appear as distinct entities; there are also mixed and transitional forms 
which clearly demonstrate their relationship. 

Etiology. — Hereditary ataxia is a family disease, often affecting 
several members of a family, and the two sexes equally; it has also 
been observed in successive generations of a family. Sporadic cases, 
however, occur quite frequently. It appears early in life, most com- 
monly between four and seven years of age, although it may begin 
much later, even at thirty. The cerebellar type (Marie) usually sets 
in later in life, at about twenty years of age, yet may begin in early 
childhood. There is a history of alcoholism, syphilis, epilepsy, or 
insanity in the parents. Not infrequently it follows certain infectious 
diseases. 

Pathological Anatomy. — Either the spinal cord or cerebellum, or 
both, depending upon the form, whether spinal, cerebellar, or mixed, 
are diminished in size and show degenerative changes. 

Of the degenerative changes in the cord there is sclerosis, which 
involves: (1) The posterior columns — the column of Goll com- 
pletely, and the column of Burdoch only partially; (2) the lateral 
columns — degeneration of the ganglion cells of Clark's column, of 
the direct cerebellar tract, of Gowers's tract, and the crossed pyramidal 
tract in the lumbar region; (3) at times the anterior columns of the 
cord. In the cerebellum there are degenerative changes in the 
Perkinje cells of the cortex, and of the cerebellar nuclei. 



HEREDITARY ATAXIA 805 

Spinal Form: Symptoms. — The most characteristic symptom is 
locomotor ataxia, beginning in the lower extremities. The child 
walks with its legs widely separated, taking small steps, and sway- 
ing to-and-fro like a drunken man. Ataxia of the upper extremities 
sets in later, frequently associated with a simple or an intention 
tremor which involves the entire body, especially the head and shoul- 
ders, causing a wobbling of the head and shoulders or whole body; 
in addition, there are at times choreic or athetoid movements. Static 
ataxia is frequently present; i. e., ataxia of the body when standing 
erect or on extending a limb. A true Romberg sign does not usually 
appear. 

Sensory disturbances are generally lacking. The deep reflexes 
are diminished or abolished, although the Babinski phenomenon 
may often be present. The other skin reflexes are normal. The 
sphincters usually escape. 

Nystagmus is a characteristic symptom. The pupillary reactions 
are normal, and optic nerve atrophy and ocular palsies rarely occur. 
Speech disturbances are common, the speech being slow, awkward, 
and at times scanning. 

Deformities are the rule. Scoliosis is frequently observed. The 
deformity of the foot is characteristic. There is talipes equinovarus, 
with the dorsum bowed, the big toe flexed dorsally, and the remaining 
toes assuming a claw-like appearance. A claw-hand (main en griffe) 
is also observed at times. These contractures are secondary to 
muscular atrophy. Trophic changes do not occur. The intelligence 
is normal. 

The cerebellar type (Marie) differs in that it usually begins after 
puberty. The ataxia is of the cerebellar type. Optic nerve atrophy 
and ocular palsies are quite frequent, and the deep reflexes are exag- 
gerated. Sensory disturbances are common. Between these two types 
numerous transitional forms have been described, with one or the 
other type predominating. 

Differential Diagnosis.— The disease must be differentiated from 
multiple sclerosis, cerebellar tumor, juvenile tabes, and cerebral 
syphilis. Multiple sclerosis is very rare in early childhood, and in 
this affection nystagmus and intention tremor are generally more 
marked. From cerebellar tumor it can be distinguished by the absence 
of the general symptoms of brain tumor — headache, vomiting, optic 
neuritis — and by ■ its more chronic course. From multiple neuritis 
it can be differentiated by the history. Juvenile tabes is very rare. 

It is characterized by lightning pains, headache, crises, pupillary 
changes, optic atrophy, and bladder disturbances. From cerebral 
syphilis or juvenile tabes Friedreich's ataxia is distinguished by the 
absence of a positive Wassermann reaction, both in the blood serum 
and spinal fluid, and by an entirely negative spinal fluid. 

Prognosis.— The course of the disease is slow and progressive, but 
several years may elapse before the patient is bed-ridden. It may 
be arrested for a time, and may extend over a period of thirty years, 



806 THE NERVOUS SYSTEM 

but is incurable. Death usually results from some intercurrent 
affection. 

Treatment. — No drugs have any influence upon the course of the 
disease. These patients should have plenty of fresh air, sunshine, 
and good nourishing food. Massage and Frenkel's reeducation 
movements should be employed. When the patient is bed-ridden, 
care must be taken to prevent contractures. 

TUMORS OF THE SPINAL CORD. 

Tumors of the cord are rare in childhood, but two main types 
may be distinguished: 

1. Extramedullary tumors, arising from the spinal meninges, of 
which we may further differentiate two varieties — the extradural and 
intradural. 

2. Intramedullary tumors which form within the spinal marrow. 
Extramedullary tumors are the more common, and among these 

are sarcoma, myxosarcoma, angiosarcoma, endothelioma, syphiloma, 
miliary tubercle, fibroma, mixed tumors, and, in infancy especially, 
associated with congenital malformations of the cord, also lipoma 
and teratoma. Of the intramedullary variety, there are solitary 
tubercles, gummata, sarcomata, and gliomata. Until ten years of 
age the tubercle is the most common intramedullary tumor, whereas 
lipoma and sarcoma are the most frequent extramedullary tumors. 

Symptomatology. — This depends upon the nature of the tumor, 
whether intramedullary or extramedullary, also upon its position. 
The symptoms complained of result from pressure upon the spinal 
roots, spinal marrow, and vertebral column. The first is intense 
pain of neuralgic, lancinating character, due to irritation of the poste- 
rior roots. The location of the pain depends entirely upon the position 
of the tumor. Hyperesthesia and certain trophic disturbances, such 
as herpes zoster, may at times be present. These may be the only 
symptoms, but may extend over several years. In some cases the 
tumor involves the motor roots, and causes irritative symptoms — 
fibrillary contractions, or even true muscle spasms. 

As a result of compression of the cord there is paralysis of both 
the sensory and motor nerves, which arise from the segments of the 
cord in which the tumor lies. There is also flaccid paralysis, muscular 
atrophy, the reaction of degeneration, loss of reflexes, and anesthesia 
as regards touch and pain. 

Indirect spinal symptoms due to interference of the pyramidal tract 
give rise to spastic hemiplegia or paraplegia, according to the extent 
of the involvement — whether unilateral or bilateral — also marked 
spasticity, muscular weakness, exaggerated reflexes, the Babinski 
and Oppenheim phenomena, and trophic and sphincter disturbances. 
At the onset the lesion is usually unilateral, and frequently produces 
the typical Brown-Sequard syndrome. On the side of the tumor there 
is (1) paralysis which is flaccid at the level of the lesion, and spastic 



TUMORS OF THE SPINAL CORD 807 

below; (2) disturbance of the muscle sense while other senses remain 
normal, except for a hyperesthetic zone above the paralysis at the 
level of the tumor. On the opposite side there is either partial or 
complete anesthesia to pain and temperature. 

Unilateral tumors very quickly become bilateral, when this clas- 
sical syndrome will change to that of a transverse myelitis. The 
symptoms naturally depend upon the position of the tumor. Tumors 
in the cervical region give rise to a spastic paralysis of all the extremi- 
ties, except that there is a flaccid paralysis of certain groups of muscles 
of the arm. If the upper portion of the arm be involved, the phrenic 
is often affected; if the lower portion, the forearm and hand exhibit 
a flaccid paralysis. Ocular symptoms may also appear. In the dorsal 
region the arm remains free with spasticity of the lower extremities, 
together with flaccid paralysis of the abdominal muscles, and loss 
of the abdominal reflexes. If located in the lumbar region there is 
general flaccid paralysis of the lower extremities. The most frequent 
location for a tumor in children is in the cauda equina. In these cases 
pain in the sacral region is very severe, and extends into the legs. 
The paralysis is a flaccid one, and bladder, rectal, and trophic 
disturbances are usually present. 

As a result of pressure upon the vertebral column and erosion of 
the vertebrae by extramedullary tumors, one occasionally observes 
scoliosis and kyphosis. Pain on percussion of the vertebras is fre- 
quently present. Oppenheim called attention to an impairment of the 
percussion note over the tumor. 

Diagnosis. — Intramedullary tumors, owing to their unfavorable 
progress, must be differentiated from those of extramedullary type 
which are more amenable to treatment. The following table gives 
the chief points in the differential diagnosis; yet it must be borne in 
mind that the differentiation is usually not easy, and frequently is 
impossible : 

Intramedullary Tumors. Extramedullary Tumors. 

Root symptoms usually absent. Root symptoms usually present. 

No pain on vertebral percussion. Pain on vertebral percussion. 

Become bilateral quickly. Remain unilateral for a longer period : 

Brown-Sequard syndrome. 
Remissions frequent. Remissions rare. 

The rapidity with which the intrameningeal tumor becomes bilateral 
tends to mask the real disease and obscure the diagnosis. If the 
anterior horn cells be involved, progressive muscular atrophy may 
be suspected; if both the anterior and posterior horn cells, syringo- 
myelia is simulated; if of diffuse character, then transverse myelitis 
may be thought of. In addition, spinal syphilis, multiple sclerosis, 
and compression myelitis must frequently be differentiated from 
tumor. 

Course and Prognosis. — The course of* the disease is usually slow, 
extending over a period of ten to twelve years, and unless operated 



808 THE NERVOUS SYSTEM 

upon, terminating fatally as a result of the extensive paralysis or by 
some intercurrent infection. 

Treatment. — If extradural, the tumor should be removed surgically. 
Tumors associated with spina bifida, and brain, metastatic and 
extradural tumors are not amenable to operation. When syphilis is 
suspected, antisyphilitic treatment should be begun immediately. 



DISEASES OF THE MENINGES. 

PACHYMENINGITIS. 

Pachymeningitis is an inflammation of the mucous membrane .which 
lines the dura, and is a rare disease in children. We distinguish two 
forms of the affection: (1) Pachymeningitis externa; and (2) pachy- 
meningitis interna. 

Pachymeningitis Externa. — This may appear either in a chronic 
fibrous form, usually associated with a chronic inflammation of the 
pia arachnoid (leptomeningitis and meningo-encephalitis) , or be 
secondary to lesion of the contiguous bony structures, such as frac- 
ture of the skull, or tubercular or syphilitic periostitis. Or it may be 
acute, and secondary to inflammation of the neighboring bony struc- 
tures, such as otitis media, mastoiditis, caries of the middle ear, puru- 
lent rhinitis, or inflammation of the sinuses, especially the frontal; 
it may lead to an extradural abscess between the dura mater and 
bony structures. 

Symptoms. — In many mild cases there are no characteristic symp- 
toms; whereas, in the more severe type there may be violent headache 
with localized pain on pressure and percussion. In the most aggra- 
vated cases symptoms of intracranial pressure, i. e., headache, pro- 
jectile vomiting, slow pulse, stupor, and choked disk may appear. 
Focal symptoms are usually absent. 

Diagnosis. — Pachymeningitis must be differentiated from the other 
complications of otitis media; namely, purulent sinus, phlebitis, brain 
abscess, and purulent leptomeningitis. 

Treatment. — The treatment is purely surgical. 

Pachymeningitis Interna. — Two forms of pachymeningitis interna 
are distinguishable: (1) Purulent; (2) hemorrhagic. 

Purulent Pachymeningitis Interna. — The purulent type usually 
results from perforation in pachymeningitis externa, and is associated 
with inflammation of the pia mater (leptomeningitis). 

Pachymeningitis Interna Hemorrhagica. — Rosenberg, of Finkelstein's 
Clinic, by his studies of pachymeningitis interna hemorrhagica, has 
extended our knowledge of the disease. It is by no means as infre- 
quent as was formerly supposed; for Rosenberg collected 48 cases 
from this Clinic within four yfcars. The disease can now be diagnosed, 
is amenable to treatment, and therefore of greater interest. 



PACHYMENINGITIS 809 

Etiology. — Pachymeningitis interna hemorrhagica is usually second- 
ary to gastro-intestinal disturbances, malnutrition, lues, rickets, scurvy, 
or infectious diseases, especially to smallpox, typhoid fever, and, 
occasionally, to pneumonia and tuberculosis. Hemorrhagic rhinitis, 
both luetic and diphtheritic, occurring from two to four months before, 
has frequently been found by Rosenberg to be an etiological factor. 
Children cared for in hospitals and institutions are more susceptible 
on account of their greater exposure to infection. 

Pathological Anatomy. — The lesions are bilateral, and are on the 
convexity of the brain, in the region of the anterior and middle fossae, 
and over the region of the middle meningeal artery and superior 
longitudinal sinus. 

In aeute cases extravasations are observed upon the inner surface 
of the dura, enclosed in a fine fibrinous connective-tissue membrane 
containing leukocytes. The membrane later becomes translucent. 
It consists of fibrous lamella? containing fibroblasts and newly formed 
vessels from the dura. The vessel walls are thin, being lined simply 
with endothelium. Hemorrhage takes place by diapedesis or by capil- 
lary bleeding, as a result of which hematoma are formed. Rosenberg 
attributes the changes to thrombosis of the sinus cavernosus. 

Symptomatology. — The clinical picture is essentially the same 
as that seen in leptomeningitis, except that fever is usually lacking. 
Rosenberg distinguishes three forms of the disease, grouped as follows: 

1. The latent form, which may show merely enlargement of the 
cranium, open and distended fontanelles, and a widening of the sutures. 
These may be the only symptoms. 

2. This variety sets in with symptoms of acute cerebral pressure, 
giving rise to vomiting, headache, convulsions, rigidity of the neck, 
stupor, and increased reflexes. 

3. A rapid form with severe symptoms arising in the nervous system, 
and simulating acute leptomeningitis. There are contractures of the 
extremities, rigidity of the neck, fever, coma, convulsions, strabismus, 
retinal hemorrhages, choked disk, and a positive Kernig's sign. 

Diagnosis. — Clinically, the disease must be differentiated from sinus 
thrombosis, leptomeningitis, and brain tumor. An invaluable aid 
to the diagnosis is a study of the cerebrospinal fluid obtained by 
lumbar puncture. It is usually clear, and under increased pressure. 
When a communication exists with the subarachnoid space, owing 
to a torn pia, the fluid will be either hemorrhagic or of a lemon-yellow 
tint. When hemorrhage due to faulty technic can be excluded, these 
findings are pathognomonic. 

A more reliable method of diagnosis is to puncture the large fontanelle, 
and withdraw some cerebrospinal fluid. (For the technic of cerebral 
puncture see page 778.) The fluid obtained is always hemorrhagic, 
but does not clot upon standing. After the cells have settled, it is 
seen to be of a light lemon color. Examination of the fluid shows no 
pathological cellular increase; there is, however, an increase in globulin, 
and a normal reduction of Fehling's solution. 



810 THE NERVOUS SYSTEM 

Clinical Course and Prognosis. — Under appropriate treatment the 
prognosis is more favorable than was formerly supposed. In Rosen- 
berg's series of cases there were 16 recoveries and 21 deaths; only 
3 of these deaths could be attributed to trie disease, the remainder 
being due to intercurrent infections. Healing follows the absorption of 
the fluid, after which the fontanelles close, the cranium again assumes 
its normal shape and size, and there is a corresponding amelioration 
of all the other symptoms. In untreated cases, however, death takes 
place within a few weeks. 

Treatment. — There should be absolute rest in bed, and the nutrition 
of the child should be carefully watched. An ice-bag should be applied 
to the head, and lumbar punctures made repeatedly, removing from 
50 to 100 c.c. of fluid at each puncture. Should improvement not 
follow, cranial aspiration should then be performed. After the removal 
of fluid, hemorrhages are likely to recur, and horse serum or human 
blood serum should be injected intramuscularly or intravenously as 
a prophylactic. If bleeding is due to syphilitic infection, appropriate 
antisyphilitic treatment must be immediately begun. 



ACUTE SUPPURATIVE MENINGITIS. 

Under this heading may be grouped all forms of meningitis except 
the tuberculous and cerebrospinal, which are considered elsewhere 
in this work. Acute suppurative meningitis is also called acute 
simple meningitis, acute purulent meningitis, and vertical meningitis, 
although it cannot be considered as a distinct disease, but should 
be regarded as a pathological condition due to infection by any one 
of a number of microorganisms. 

It is customary to designate the forms of meningitis in this group 
according to the causative organism; e. g., influenzal meningitis, 
streptococcic meningitis, and pneumococcic meningitis. Clinically, 
these forms of the disease so closely resemble each other that the 
grouping of all the various types seems justified. 

Etiology. — Acute purulent meningitis may be either primary or 
secondary, the primary form being most frequently of pneumococcic 
or influenzal origin, while secondary meningitis is generally caused 
by the staphylococcus. Meningitis may, however, arise from any 
acute systemic infection with bacteremia. 

Among the rare causes of acute purulent meningitis are trauma 
and insolation. Meningitis may also develop from the extension of 
a suppurative process in the scalp, cranial* bones, nasal cavities, the 
ear, the orbit, and the face, from the rupture of brain abscesses, or 
may be produced by more distant lesions, the infection being carried 
by the blood or the lymph stream. 

The meninges are sometimes the site of infection by the colon 
bacillus, and meningitis may also accompany scarlet fever, measles, 
diphtheria, smallpox, rheumatic fever, typhoid fever, erysipelas, 



ACUTE SUPPURATIVE MENINGITIS 811 

pneumonia and influenza, and may occur as a terminal infection in 
many chronic infectious diseases. 

The bacillus pyocyaneus and, more rarely, the gonococcus are 
isolated in some cases, while in others there may be more than one 
variety of organism, the process being due to mixed infection. Chil- 
dren of all ages are attacked; as a rule, the previous state of health 
seems to have no influence on the occurrence of this meningeal inflam- 
mation. Most of the cases occur sporadically, and are probably more 
frequent during the late winter and spring months than at other 
seasons of the year. 

Pathology. — The dura mater, the pia mater, or both may be affected; 
usually the pia mater is most extensively involved, the inflammatory 
process being a general one; but it may also be more or less localized 
to a limited area. Thus, the spinal cord, the cortex of the brain, the 
ventricles of the brain, or all of these may be the site of inflammation; 
or, as in the cases where there is infection of the ear, for example, 
the lesions may be unilateral. The vessels of the pia are congested, 
minute hemorrhages take place, and serofibrinous or purulent fluid 
bathes the parts. The convolutions may be flattened, and the pia 
arachnoid, or even the ventricles, may be quite distended. As a rule 
there is associated involvement of the spinal cord. 

When the inflammatory process is confined to, or is most extensive 
over, the vertex, it is sometimes termed vertical meningitis. In pneu- 
mococic meningitis the bulk of the exudate and many adhesions are 
found in the upper portion of the brain. Not uncommonly, the ante- 
rior half of the brain may be encased in pus. Microscopic exami- 
nation of the affected tissue reveals marked congestion of the blood- 
vessels and round-cell infiltration in the inflammatory areas. 

Symptoms. — In the majority of cases of acute purulent meningitis 
the onset is sudden and the symptoms violent; although in some 
instances the first symptoms of meningitis may be masked to a con- 
siderable extent by the primary disease, especially if this be erysipelas, 
septicemia, or pneumonia. Drowsiness and stupor, with irregular 
respirations and pulse, may be the first indications of meningitis. 
In primary cases, due to the pneumococcus and influenza bacillus, 
vomiting and convulsions usually usher in the attack. As a rule there 
is an initial chill, followed by a sudden rise in temperature, severe 
headache, increasing delirium, photophobia, rigidity and retraction 
of the neck, aimless movements of the legs and arms, general signs of 
irritation, dilatation of the pupils, and finally coma. A bulging of 
the anterior fontanelle is often apparent in young infants, and Kernig's 
sign is present in all cases. 

Diagnosis. — As a rule, the diagnosis of acute purulent meningitis 
can readily be made from the symptoms; but in order to determine 
the particular type with which we are dealing an accurate history 
must be taken, the symptoms thoroughly investigated, and a bacte- 
riological examination of the cerebrospinal fluid made. Although the 
symptoms of the various forms of meningitis may be somewhat dis- 



812 THE NERVOUS SYSTEM 

similar, and while we may suspect from the history of the case that 
a certain type of the disease is present, neither of these circumstances 
is of any practical value, and the only conclusive evidence of a certain 
infection is the finding of the specific organism within the spinal fluid. 

Pneumococcic Meningitis. — Of the various forms of meningeal 
inflammation grouped under the heading of acute suppurative menin- 
gitis, this is the one most frequently met with in young children. It 
is practically always associated with general pneumococcic infection 
and pneumococcemia, and in most cases there is a demonstrable lesion 
in the bronchi, lungs, pleura?, pericardium, or peritoneum. Although 
in occasional cases no pneumococcic lesion is evident, yet at post- 
mortem the pneumococcus can invariably be isolated from the heart's 
blood. 

The meninges usually become involved during the height of an 
attack of pneumonia, but meningitis occasionally precedes or follows 
pulmonary consolidation. 

As a rule, in any series of cases the majority will be found to occur 
in infants under one year of age. At autopsy the gross changes 
resemble those of cerebrospinal meningitis, but there is little, if any, 
involvement of the cord. The fibrinous and purulent exudation is 
more profuse than in any other type of meningeal inflammation. 

Symptoms.— The symptoms closely resemble those of cerebrospinal 
meningitis, but in many cases there is entire absence of rigidity, cer- 
vical opisthotonos, Kernig's sign, and hyperesthesia, while the pulse 
and respirations may not be appreciably altered. The onset is sudden, 
the course of the disease is short and violent, being, as a rule, from two 
to eight days, rarely longer. A positive diagnosis can be made only 
by examination of the cerebrospinal fluid, which is cloudy, under 
increased pressure, and contains an excess ofpolynuclear leukocytes 
and many pneumococci grouped in short chains. 

Septic Meningitis — Streptococcic Meningitis — Staphylococcic Men- 
ingitis. — This form of meningitis is usually secondary, and is a com- 
plication of septicemia, otitis, mastoiditis, trauma, erysipelas of the 
scalp, sinus thrombosis, infection of the umbilicus, or of spina bifida. 
The symptoms are not quite as severe as in pneumococcic meningitis; 
but the disease is usually fatal, especially the streptococcic type, which 
is more severe than that due to the Staphylococcus pyogenes. 

Examination of the brain reveals diffuse inflammation of the pia 
and a profuse purulent exudate, but not the excess of fibrin so char- 
acteristic of pneumococcic meningitis. The cerebrospinal fluid is 
turbid, is under increased pressure, and contains numerous pus cells 
and streptococci or staphylococci, the streptococci being usually 
grouped in long chains. 

Influenzal Meningitis. — This form of acute purulent meningitis 
occurs in association with influenzal infection elsewhere in the body, 
but is very rare. Infants are more liable to attack than older children. 
Most of the reported cases have been secondary to involvement of 
the nose, throat, or bronchi. The postmortem findings are the same 



ACUTE SUPPURATIVE MENINGITIS 813 

as in pneumococcic meningitis, and the influenza bacillus may be found 
in the heart's blood and in the primary lesions, as well as in the 
cerebrospinal fluid. 

Symptoms. — The onset of this form of meningitis is not quite so 
sudden as in the pneumococcic type, but the symptoms are acute and 
violent. In the great majority of cases, an attack ends fatally within 
a few days after the appearance of the initial symptoms. The mor- 
tality in influenzal meningitis is not quite as high as in the preceding 
forms of meningeal inflammation in this group, but recovery is 
unusual. 

Diagnosis. — The diagnosis can be made only by microscopic exam- 
ination of the cerebrospinal fluid and by making cultures therefrom, 
since the influenza bacilli are by no means as abundant as are the 
infecting organisms in other forms of purulent meningitis, and in some 
cases they cannot be found in smears. 

The cerebrospinal fluid is turbid, and contains many polynuclear 
leukocytes in addition to influenza bacilli. In some cases organisms 
other than the influenza bacillus are present, which indicates a mixed 
infection. 

Typhoid Meningitis. — Occasionally, during the course of typhoid 
fever in children, a meningitis which is purulent in character will 
develop, the typhoid bacillus being the causative organism. The 
prognosis in this typhoid meningitis is slightly more favorable than 
in the other forms of purulent meningitis, although recovery occurs 
only occasionally. 

Differentiation of Purulent Meningitis from Other Diseases. — Men- 
ingismus, or toxic irritation of the meninges, occurring during the 
course of any illness, may simulate meningitis; but the pulse and 
respiration do not become irregular, as in meningitis, and examina- 
tion of the spinal fluid is negative. Typhoid fever is sometimes 
simulated at the onset of meningitis; but in meningitis vomiting is 
more persistent, there is rarely diarrhea, as in typhoid fever, there is no 
marked enlargement of the spleen, and the Widal reaction is negative. 

Pneumonia is sometimes mistaken for meningitis; but when physical 
signs become appreciable in the chest, the meningeal symptoms usually 
subside. Uremia may be excluded by urinalysis, and eclampsia by 
an accurate history of the case and by study of the patient for a day 
or two. 

Brain tumors may be excluded by the absence of localizing symp- 
toms, such as optic neuritis, paralyses, and other evidences of a definite 
local lesion. 

Prognosis. — The prognosis in acute purulent meningitis is most 
unfavorable, and in all the various types of the disease a large majority 
of the children perish. The mortality varies from 65 to 85 per cent., 
and is lowest in those cases where operation is resorted to for relief. 

Treatment. — Acute purulent meningitis, secondary to infection of 
the head, ears, or face, is sometimes greatly modified by free drainage 
of the infected area. Antimeningococcic serum is of no value in this 



814 THE NERVOUS SYSTEM 

form of meningitis, but repeated lumbar punctures will relieve the 
pressure symptoms. In influenzal meningitis a specific serum has 
been used by Wollstein, of the Rockefeller Institute, and others with 
good results. In the staphylococcic variety, homogeneous vaccines 
may be of service if given early in the course of the disease. 

The general management of acute purulent meningitis is the same 
as that of other forms of meningeal inflammation, although in many 
cases little can be done, except to provide nourishment for the child 
and make it as comfortable as possible. Warm baths or a hot pack 
may be given three or four times a day, and ice-bags applied to the 
head and along the spine. The child should be kept in a quiet, dark, 
and well ventilated room. 

If restless, 2 to 5 grains of sodium bromide, with \ to 1 grain of 
chloral hydrate, may be given every two or three hours to infants, and 
twice this dose to older children. If rectal administration is necessary, 
the dose should be double that given by mouth. 

In very severe cases it may be necessary to administer morphine 
sulphate, T \-§ to ^ of a grain hypodermically, or codeine sulphate, 
gV to -£$ of a grain at 4- to 6-hour intervals, or hyoscine hydrobro- 
mate, -%^-$ to -§$■$ of a grain. 

The bowels should be kept regular by giving small doses of calomel, 
yq to \ grain, during the day, or by the administration of a daily dose 
of \ to \ teaspoonful of cascara sagrada. 

Feeding is often attended by much difficulty. A liquid diet is 
preferable, and milk is the best food; but, in many cases, the child 
refuses food, while in others it is unable to swallow. Nutrient enemata 
may be resorted to, but the bowel soon becomes irritable and unable 
to retain them, and gavage is then necessary. 

The nose and mouth must be kept absolutely clean. In feeding 
the child who cannot swallow there is always danger that food may 
pass into the air passages. Bed-sores soon develop unless the child's 
skin is kept clean and dry, and precautions are taken to prevent 
pressure. 

Stimulation is rarely of any permanent value; but, when required, 
brandy, 10 to 30 drops, strychnine sulphate, ±jfQ to yor of a grain, 
atropine sulphate, -g-J-g- to ^q-q" of a grain, or camphorated oil, one to 
three drops, may be given every two or three hours. 

CEREBROSPINAL MENINGITIS— EPIDEMIC MENINGITIS. 

Definition. — This is a specific infection of the meninges of the cere- 
brospinal tract, caused by the diplococcus intracellularis meningitidis 
of Weichselbauni, and occurs both epidemically and sporadically. 

Etiology and Epidemiology. — Epidemic cerebrospinal meningitis is a 
disease of both winter and spring, reaching its height between Feb- 
ruary and May. No country has been free from its ravages, 
although countries of the north temperate zone, especially those of 
Central Europe and our own northeastern States have suffered most. 



CEREBROSPINAL MENINGITIS 815 

Age is of considerable importance, since it chiefly affects those under 
three years, the incidence diminishing as the age increases. Males 
and females seem equally susceptible. Occupation and hygienic con- 
ditions play important roles in the etiology; thus, soldiers housed 
in barracks, miners, and inmates of prisons and almshouses are 
especially susceptible. 

The diplococcus is almost invariably present, especially in the 
early stages of the disease, in the nasopharynx, particularly the 
upper part, and in the posterior nares. By making a swab, and 
then microscopic preparations, properly stained, these diplococci 
can be found. Albrecht and Shon demonstrated that healthy persons 
entirely free from the disease may harbor the cocci in the nasopharynx; 
and, according to Horder, the number of these healthy carriers varies 
from ten to thirty for every case of cerebrospinal meningitis occurring 
during an epidemic. Usually the diplococcus persists for three to 
four weeks after convalescence has set in. With regard to the carriers 
the cocci may be isolated even after several months, sometimes 
disappearing for a time, and then reappearing. 

All evidence points to direct contact as the means of dissemination. 
Owing to the low degree of vitality of the organism, dissemination 
takes place through minute droplets of the secretion in coughing, 
speaking, or sneezing. 

Pathogenesis. — The portal of entry of the infecting organism is the 
mucous membrane of the nasopharynx, where it sets up a pharyn- 
gitis, and from a study of recent epidemics it would seem that the cocci 
reach the meninges through the lymph and blood streams — lympho- 
hematogenous — this being the most frequent and the earliest manifes- 
tation of meningococcic septicemia. 

Pathological Anatomy. — In the acute fulminating cases leading 
quickly to death, there are either no visible changes or only hyperemia 
of the meninges. In the ordinary acute cases a purulent exudate, 
which is usually thick and yellowish green, is deposited in the meshes 
of the pia, chiefly at the base, especially around the optic chiasm, 
and extending to the cranial nerve-roots, cerebellum, spinal meninges, 
and to the convexity of the brain. The ventricles are distended with 
a turbid seropurulent exudate containing flakes of fibrin; sometimes 
it is purely serous, and leads to hydrocephalus. The choroid plexus 
and ependyma are always involved. Everywhere Gram-negative 
diplococci can be found microscopically. At a late stage of the disease, 
when the infection has subsided and convalescence has set in, the 
exudate has disappeared, and is replaced by fibrous thickening of 
the pia arachnoid. 

Symptoms. — Although prodromal symptoms of indisposition and 
slight headache may be present for three to four days, usually the 
onset is very sudden, with fever, with or without a chill, intense head- 
ache, vomiting, rigidity of the neck, and general malaise. The 
temperature varies between 102° and 104° F., with a corresponding 
increase in pulse rate. The headaches are usually occipital, and very 



816 THE NERVOUS SYSTEM 

severe. Vomiting may be almost continuous in young children, but 
less persistent in small infants and young adults. There may be 
slight stupor, or even delirium, during the initial period, which usually 
lasts from two to four days, following which symptoms of meningeal 
irritation develop. 

The vomiting persists, there is loss of appetite, obstinate consti- 
pation, and the abdomen becomes markedly scaphoid. The pulse 
is rapid and irregular; the respirations are also irregular. The fever 
usually runs a variable course, or may be intermittent, with days of 
normal temperature. Following the initial stage, the sensorium 
usually clears during the first week. In severe cases the spleen is 
enlarged. Albuminuria is a frequent accompaniment; at times there 
is slight glycosuria. Herpes is quite common. Other skin rashes, 
such as large rose spots, small petechias, and rashes simulating measles, 
scarlet fever, and urticaria are observed. 

Nervous Symptoms. — The most important symptom of irritation is 
rigidity of the neck, which may be marked; on any attempt to move 
it, the patient will resist and complain of severe pain. Bruidzinski's 
sign (flexion of the lower extremities on acute flexion of the head) is 
positive. Opisthotonos may likewise be extreme. The legs are drawn 
up. Kernig's sign is positive, and a positive Babinski sign may also 
be present. Tonic convulsions of the muscles of the extremities, 
abdomen, and face, are frequent; likewise clonic convulsions, especi- 
ally involving the face. Convulsions simulating epilepsy, at times 
Jacksonian, are observed. 

Hyperesthesia and hyperalgesia are most pronounced. In addition 
there is photophobia and susceptibility to noises. The vasomotor 
system is also affected, giving rise to the familiar tache cerebrale. 
Cranial and peripheral palsies are rare. The reflexes are variable; 
the deep reflexes are usually increased, although they may be normal, 
diminished, or absent. The superficial reflexes are likewise quite 
variable; they are usually increased, but later disappear. The pupils 
may be dilated or contracted, and unequal. The reactions are usually 
sluggish or absent. 

The stupor is not so deep as in other forms of meningitis, for the 
patient can usually be aroused. There may be delirium and marked 
insomnia. In infants the fontanelles are bulging. 

Clinical Forms and Course. — Horder distinguished the following forms 
of cerebrospinal meningitis: 

1. The ordinary, or acute, type just described. 

2. Super acute type. 

3. The fulminating, or malignant, type. 

4. Mild type. 

5. Postbasic meningitis of infants — cervical opisthotonos of 

infants (Gee and Barlow). 

6. Aberrant forms: 

(a) Abortive. 

(b) Intermittent. 

(c) Cases simulating other diseases. 



CEREBROSPINAL MENINGITIS 817 

In the superacute forms the symptoms are more intense, and the 
patient usually succumbs within two or three days. In the fulminat- 
ing type death may take place within twelve hours. In milder forms, 
the symptoms are less severe. This is common during epidemics, 
and unless a careful examination is made and a lumbar puncture 
performed, it may go unrecognized. The abortive cases are to be 
recognized only during epidemics; they exhibit slight fever, vomiting, 
and stiffness of the neck, all of these symptoms clearing up within 
several hours. The post-basic meningitic form is characterized by 
extreme retraction of the head, marked opisthotonos (the head fre- 
quently approximating the buttocks), vomiting and extreme emaciation. 

Course in Acute Type. — The disease either ends in recovery, inter- 
rupted by recrudescence, or becomes chronic, and the emaciation 
extreme. Incontinence and bed-sores develop, and muscular rigidity 
becomes marked. The disease may continue for months and, although 
recovery may take place and leave no residual defects, yet usually 
mental deficiency, blindness, deafness, or palsies follow. Death may 
ensue at any time during the course of the disease. 

Diagnosis. — The characteristic signs and symptoms, which are 
especially noticeable during an epidemic, will usually arouse one's 
suspicions of meningitis. An absolute diagnosis can be made only 
by thorough examination of the cerebrospinal fluid, the findings in 
which are as follows: 

(1) The spinal fluid is both increased in amount and under increased 
pressure. (2) The fluid shows turbidity which varies, being slight in 
the invasive stage, and marked during the active stage, later clearing 
as the inflammation subsides. (3) The globulin is always increased, 
the amount depending upon the stage of inflammation. (4) The fluid 
does not reduce Fehling's solution. (5) Cytology : I Hiring the invasive 
stage the lymphocytes predominate, but on the advent of acute inflam- 
mation the polynuclear cells predominate, ranging between 70 and 
80 per cent. Later, when the inflammatory stage subsides and chronic 
hydrocephalus becomes more pronounced, there will be a predomi- 
nance of lymphocytes. (6) Bacteriology of the fluid: Intracellular 
meningococci can usually be seen some time during the first ten days. 
The fact that they are not perceptible in smears does not necessarily 
indicate that they are absent, and the fluid should always be cultured 
on appropriate culture media. 

Complications. — Joint complications, either monarticular- or poly- 
articular involvement, are observed. Inflammations of the eye — 
panophthalmia, iritis, iridocyclitis, usually unilateral, and leading 
frequently to blindness — also inflammation of the inner ear, generally 
bilateral, giving rise to deafness, are all observed. Empyema, peri- 
carditis, and endocarditis are rare complications. Chronic hydro- 
cephalus frequently follows this disease. 

Prognosis. — Since the use of Flexner's serum the death-rate has 
fallen from 70 to 80 per cent, to about 30 to 40 per cent. The mor- 
tality is highest in young infants, especially in the early stages of 
1 52 



818 THE NERVOUS SYSTEM 

the disease. The prognosis cannot be made by examination of the 
spinal fluid alone; but the greater the number of intracellular cocci 
the better will be the outlook, and vice versa. 

Prophylaxis. — Since we now know that the mode of dissemination 
of the cocci is through the buccal secretions, care must be taken to 
prevent direct contact. Strict quarantine should be established, just 
as for other infectious diseases, and the same precautions observed 
in regard to the disposition of the urine, feces, and infected fomites, 
as well as thorough fumigation after recovery. 

Even more important is the treatment of the Carriers, as it is by 
them that the disease is really spread. They, likewise, should be 
placed under quarantine until the nasopharynx is free from cocci, 
which, under the use of antiseptic gargles and sprays, is usually in 
about ten days. All healthy persons should avoid the predisposing 
causes — exposure to severe cold, catarrhal affections, and overcrowding. 

Treatment. — Several immune specific sera have been made. The one 
in general use in America is that of Flexner. It must be administered 
by the intraspinal route, the method being as follows : 

A lumbar puncture should be made, and the turbid fluid withdrawn 
in an amount always equal to, or greater than, the quantity of serum 
to be injected. The serum should then be slowly injected, either with 
a syringe or by the gravity method, the time allowed for the injection 
being about ten minutes. The usual dose is 20 c.c, and a dose larger 
than this must be given with extreme care, even though a large quan- 
tity of spinal fluid has been withdrawn. This procedure is repeated 
daily until the spinal fluid has been sterile for several days, and the 
patient clinically shows great improvement. 

If the case is progressing favorably the spinal fluid clears, and les- 
sens in amount and pressure, the leukocytes rapidly diminish, the 
meningococci disappear, and the power to reduce Fehling's solution 
— of considerable importance in the prognosis — reappears. If there 
is a relapse, the same treatment is repeated. Autogenous vaccines 
have also been employed, but as yet without convincing results. 

If meningococcic septicemia develops, the serUm should be admin- 
istered intravenonsly; in hydrocephalus should be injected directly 
into the lateral ventricles; and in severe joint affections it should be 
introduced directly into the joint. 

The general treatment is of the utmost importance. The patient 
must be kept quiet, preferably in a dark room, and must be given 
plenty of fresh air. An ice-cap should be kept on the head. Hydro- 
therapeutic measures, such as warm baths, will allay the nervous 
symptoms. Hexamethylenamin should be given routinely — five 
grains three or four times a day to a child five years old. Sedatives, 
preferably some preparation of opium, may be necessary on account 
of the pain and delirium. Morphine, gr. T V, may be given hypoder- 
mically to a child of five years, and if necessary the dose may be 
repeated. Every precaution must be taken to guard against bed-sores 
and, if possible, the patient should lie on a water bed. 



TUBERCULOUS MENINGITIS 819 

The nourishment of the child should receive most careful atten- 
tion. When necessary, feeding by gavage is usually more satisfactory 
than by rectum. Attention should be given the bladder, bowels, eyes, 
skin, and ears, and, should any complications develop, they should 
receive appropriate treatment. 

• TUBERCULOUS MENINGITIS. 

Tuberculous meningitis, the most common form of meningitis, is 
a tuberculous inflammation of the cerebrospinal meninges, developing 
secondarily to some tuberculous focus elsewhere in the body or as a 
part of a general tuberculosis. 

Etiology.— Tuberculous meningitis is a disease of early childhood, 
occurring most frequently between the second and sixth years. It 
has been observed as early as the third month, and after the sixth 
month has been found quite frequently. After the sixth year, cases 
of the disease rapidly diminish. The sexes seem equally affected. 
The disease is most common in the early spring, from March to May. 
Breast-feeding offers no immunity to this infection. 

The disease is always caused by the tubercle bacillus. The cerebro- 
spinal meninges are never involved primarily; but the infection arises 
from some latent tuberculous focus elsewhere in the body, such as the 
caseous bronchial, cervical, mediastinal, or mesenteric lymph glands, 
lesions in the lungs, pleura?, bones, joints, and intestines, or tubercu- 
lous meningitis may be merely a part of a general miliary tuberculosis. 

Pathogenesis. — The pathogenesis of tuberculosis in children is con- 
sidered in the chapter on Tuberculosis. It seems well established 
by the studies of von Pirquet, Hamburger, and, more recently, by 
those of Dunn that in the great majority of cases infection takes place 
through the respiratory tract, that the bacilli lodge in the lung where 
they set up a primary focus of infection, and that the regional lymph 
glands become secondarily involved through the lymph vessels. 

From the primary focus of infection the bacilli invade the bronchi, 
thence pass to the nasopharynx and its regional lymph glands. By 
the swallowing of the bacilli in the sputum they reach the intestinal 
tract, thence the mesenteric lymph glands, and peritoneum. Occa- 
sionally, through drinking milk infected with the bovine type of 
bacillus, the intestinal tract is the primary seat of the lesion. 

The most frequent mode of infection of the meninges is through 
the blood stream, either directly from the primary focus in the lungs 
or from some secondary focus, such as a caseous lymph gland, which . 
perforates into a vein, and causes the dissemination of the bacilli to 
all the organs of the body, setting up a miliary tuberculosis. Peritz 
attributes the frequency with which meningitis develops in the child 
to the increased demand for blood on the part of the rapidly growing 
brain. 

In addition there are a number of factors which have an exciting 
influence upon these tuberculous foci, and lead to tuberculous menin- 



820 THE NERVOUS SYSTEM 

gitis. Thus certain infections, especially measles and whooping-cough, 
predispose to tuberculous meningitis, possibly owing to diminished 
resistance due to these infections. Trauma, such as injury to the 
head, tuberculous glands or joints, or operations for the removal of 
glands, may cause a dissemination of bacteria, either by direct injury 
to the active focus, or by a lessening of the resistance of the arachnoid 
membrane, such as is caused by a blow upon the head. Overexertion, 
mental excitement, and strain have precipitated tuberculous menin- 
gitis. 

In rare cases the meninges may be infected by tuberculosis of the 
contiguous structures, such as caries of the inner ear, vertebras, or 
cranial bones. 

Pathological Anatomy. — Tuberculous meningitis is primarily a basilar 
meningitis. The most important pathological changes are the miliary 
tubercles and the inflammatory exudate which are found especially 
at the base of the brain around the circle of Willis and optic chiasm, 
extending into the Sylvian fissure, and out over the pons, the base 




Fig. 83. — Opisthotonos in tuberculous meningitis; a boy six years of age. 

of the medulla oblongata, the cerebellum, and spinal meninges. The 
exudate is either gelatinous, serofibrinous, or greenish-yellow and of 
fibrinopurulent character; owing to its consistency, it is adherent 
to the pia. The amount of exudate is relatively small compared with 
that in other types of meningitis. 

The tubercles, either transparent or of a greenish-white color, are 
especially numerous about the base of the cerebrum. They are often 
observed arranged in rows along the vessels of the Sylvian fissure 
after the removal of the pia. The convexity of the brain is less 
involved, although there may be cloudiness, and an infiltration of 
the pia with tubercles. The ependyma and choroid plexus of the 
lateral ventricles are also invaded by tubercles with resulting internal 
hydrocephalus. The ventricles become filled and distended with a 
clear serous fluid, or it may be bloody. As a result of pressure the 
walls may be softened, the convolutions flattered, the fontanelles 
bulging, and the sutures separated. 

The dura may at times exhibit a mild pachymeningitis interna 
hemorrhagica, or may be infiltrated with tubercles. The cerebral 



TUBERCULOUS MENINGITIS 821 

cortex is always involved. Tubercles may invade the cortex and 
caseate, giving rise to a meningoencephalitis. 

Symptoms. — The onset of the disease is usually slow and gradual, 
occurring most frequently in weak, anemic, and poorly nourished 
children. On the other hand, children presenting the very picture of 
health may likewise be affected. The disposition of the child slowly 
changes, and it loses interest in its play, becomes irritable, fretful, 
peevish, easily tired, moody, wishes to be let alone, cannot be pleased, 
and is drowsy and sleepy. Its sleep is restless, interrupted by slight 
delirium, or there may be insomnia. Headache, which at first is mild 
and periodic, rapidly becomes more severe and persistent. Symptoms 
referable to the gastrointestinal tract develop. There is loss of appe- 
tite, vomiting, pain in the abdomen, and severe constipation. The 
vomiting is cerebral in character, projectile, and is unassociated with 
nausea or time of eating. 

These prodromal symptoms last from several days to weeks, or 
even months, in which time, however, symptoms of cerebral irri- 
tation have gradually developed. There is hyperesthesia of the skin 
and sense organs. The patient is susceptible to harsh voices or bright 
lights; merely the slightest touch is painful. In addition there are 
certain vasomotor phenomena, such as transient flushing of the cheeks, 
face, and body. The well-known tache cerebrale is almost always 
present. This is an irritation of the skin, manifested by a red streak 
which appears when the finger-nail is drawn over the skin of the 
abdomen. 

There are also slight symptoms of motor irritation. The child per- 
forms certain stereotyped movements; it picks at its lips, genitals, 
and bed-linens, winks its eyes, grinds its teeth, performs sucking and 
chewing motions, and from time to time takes deep sighing inspirations. 

At this stage, although drowsy, the child may answer questions 
coherently. The temperature is usually elevated in the evening to 
100° or even 102° F., the pulse is usually between 70 and SO, and 
exhibits marked arrhythmia. The patulous fontanelles may be dis- 
tended and pulsating. The pupils are usually contracted, and react 
promptly. Exaggerated reflexes are, as a rule, present, although 
they may be unequal. Slight rigidity of the neck, back, and lower 
extremities may give rise to a positive Kernig's sign, also to Bruid- 
zinski's sign (on passive flexion of the head upon the chest, the thighs 
are drawn up upon the abdomen). 

The symptoms of cerebral pressure and irritation grow worse. 
The drowsiness increases, and the child sinks into a stupor from which, 
however, it can be aroused. Acute irritative symptoms may set in, 
with severe headache, delirium, convulsions, and finally deep stupor. 
The delirium is usually mild. The child lies almost asleep, with its 
eyes half-open, and performs stereotyped movements, utters inco- 
herent sounds, and throws itself back and forth on the bed or fre- 
quently utters piercing shrieks — the hydrocephalic cry. Stupor 
follows the delirium, or thev mav alternate. 



822 THE NERVOUS SYSTEM 

When the sensorium again clears, severe headache and dizziness 
are complained of. There is increased susceptibility to strong light 
— photophobia — and to loud noises; the symptoms of motor irri- 
tation are increased; the rigidity of the muscles of the neck, trunk, 
and extremities also increases. Tetanic contractions of the muscles 
of the jaw and face may take place, while contractions of the flexor 
muscles of the lower extremities give rise to a characteristic posture; 
i. e., the patient lies upon the side, with the thighs flexed upon the 
abdomen, and the legs upon the hips. The abdomen is usually 
retracted, which gives it a "boat-shaped" appearance. As a result 
of the extreme emaciation the intestines can be readily palpated. 

Paralyses are quite frequent, and cranial nerve palsies common, 
owing to the extensive basilar involvement. There are ptosis, dilata- 
tion, and inequality of the pupils, strabismus, and, occasionally, 
complete ophthalmoplegia. The pupils react slowly to light or are 
inactive. Nystagmoid movements are often seen. Examination of 
the eye-ground frequently shows a choked disk and the presence of 
miliary tubercles in the choroid. Facial paralysis is also often observed. 
Paralyses of the extremities, such as monoplegia or hemiplegia, may 
follow convulsions, which may be either partial or complete; if 
unilateral, they may simulate a Jacksonian epileptic seizure. 

The reflexes are usually increased. A positive Babinski phenomenon 
may or may not be present. As unconsciousness deepens the reflexes 
are lost, the temperature rises, and the breathing becomes Cheyne- 
Stokes. Remissions in this state are not rare; they are only tem- 
porary, however, and after several days of improvement the patient 
falls into the final stage of coma. 

In this stage there is complete unconsciousness, a relaxation of the 
hitherto rigid extremities and neck, the reflexes are gone, the pupils 
are dilated and show no reaction, the vomiting and the outcries cease. 
There may be either retention of urine or incontinence of both urine 
and feces. The pulse always becomes rapid and feeble, frequently 
170 to 200 or more per minute; the temperature rises, and during the 
last few days may reach 106° to 107° F.; it may, however, be sub- 
normal. Death usually follows, or may occur during a convulsion. 
This final stage extends over a period of three to ten days, while the 
duration of the whole disease after definite symptoms have appeared 
is from two to four weeks. 

Atypical Cases. — Acute Cases. — In a few cases the onset is very acute, 
the disease setting in with convulsions, after which the patient quickly 
falls into coma, which terminates in death within a few days. 

Meningoencephalitis. — Following convulsions, monoplegia or hemi- 
plegia may appear, due to involvement of the motor area. 

Spinal. — In rare cases, lancinating pains are complained of, due to 
involvement of the spinal roots. 

Chronic Form. — Such cases have been described, extending over a 
period of months, in which remissions lasting weeks and months have 
taken place. 



TUBERCULOUS MENINGITIS 823 

Diagnosis. — The diagnosis during the prodromal period may be 
very difficult; although the vomiting, severe headache, drowsiness, 
change in disposition, and irregular pulse and respirations should 
arouse one's suspicions of some form of meningitis. 

An absolute diagnosis of tuberculous meningitis can usually be 
made by examination of the cerebrospinal fluid, which also enables 
one to differentiate between the various types of meningitis. The 
fluid removed by lumbar puncture is under great pressure, and is at 
first usually clear or slightly turbid, later opalescent or turbid, or may 
even be purulent (owing to mixed infection). There is generally a 
relatively slight cellular increase, in which the mononuclear cells 
predominate. As the spinal fluid becomes secondarily infected, the 
polynuclear elements predominate. 

As a rule, there is a great excess of globulin. There may or may 
not be a reduction of Fehling's solution, depending upon the type 
of cells that predominate; if the mononuclear cells are in excess the 
solution reduces, whereas if the polynuclear elements increase this 
reducing power diminishes. 

An absolute diagnosis of tuberculous meningitis can only be made 
by isolating the bacilli from the spinal fluid. This can be accom- 
plished in practically every case, although it usually requires a long, 
diligent* search. Repeated punctures are frequently necessary. The 
technic of the procedure is as follows : 

From 10 to 20 c.c. of spinal fluid are put in an ice chest and allowed 
to stand twelve to twenty-four hours, during which time a fine fibrinous 
coagulum, resembling a spider web, usually forms. This coagulum 
is carefully floated out upon a glass slide, then teased out, and finally 
stained for the tubercle bacillus. In other cases centrifuging may be 
necessary, and a preparation made of the precipitate. In still other 
cases superimposing drop upon drop, obtained by scraping the side 
of the test-tube with a platinum loop, may give the desired result. 
Should it be unsuccessful, then an intraperitoneal inoculation of the 
spinal fluid should be made in a guinea-pig, in which case the diagnosis 
will be confirmed only after the death of the patient. 

In addition other means of diagnosis should be employed. Tubercle 
bacilli can often be isolated from the sputum. Tuberculin reactions 
— those of von Pirquet, of Moro, and of Monteau — assist by estab- 
lishing the presence or absence of tuberculous infection. In a series 
of cases reported by Koch, from von Pirquet 's Clinic, 84 per cent, 
gave a positive reaction during the second week before the child died, 
dropping to 65 per cent, in the last week of the illness. The tuber- 
culous reaction diminishes during the last stage. 

Other evidences of tuberculosis should also be sought for. By a 
physical examination enlarged bronchial glands or active lung foci 
may be determined, and be confirmed by the arrays; at times the 
primary focus of infection in the lungs is shown by the .T-rays, and 
should always be looked for. The clinical symptoms, combined with 
the laboratory findings, usually establish the diagnosis. 



824 THE NERVOUS SYSTEM 

Prognosis. — Tuberculous meningitis is almost always fatal. There 
are, however, a few authentic recoveries recorded, in which tubercle 
bacilli were present in the spinal fluid; yet, considering the length 
of the remissions, it is necessary to keep these patients under obser- 
vation for a long period of time before pronouncing them cured. 

Prophylaxis. — The child should be carefully guarded against any 
possible tuberculous infection. This is considered more fully in the 
chapter on Tuberculosis. If it becomes infected, then the greatest 
care should be exercised to prevent mental excitement, overexertion, 
and to protect the child from the infections — measles and whooping- 
cough — which so frequently precipitate meningitis. 

Various procedures have been advised for the treatment of this 
disease, but none have been effectual. Drainage of the subarachnoid 
spaces, also ventricular puncture, have been suggested. Irrigation 
of the spinal canal has also been performed. The least harmful pro- 
cedure is lumbar puncture, which should be repeated as often as 
necessary for the relief of symptoms. Improvement usually follows 
this procedure, but death ensues later. 

Treatment. — Our field for treatment lies in prophylaxis; since, 
after the disease has been established, the treatment can be only 
symptomatic. 



DISEASES OF THE BRAIN. 



CEREBRAL PALSIES. 

In the symptom-complex of cerebral palsies are included a variety 
of clinical manifestations, the remains of former cerebral diseases, 
of various anatomical lesions, and etiological factors, leaving behind 
certain permanent anatomical lesions and clinical disabilities. From 
a single symptom it is impossible to make a definite anatomical 
diagnosis. 

Etiology. — Cerebral lesions giving rise to cerebral palsies may occur 
as follows : 

1. Causes Prior to Birth. — Malformations of the brain, porenceph- 
alia, microcephalia, and cysts are frequently associated with malfor- 
mations elsewhere in the body, as in the kidneys, heart, etc. Fright, 
anger, sorrow, or trauma may give rise to hemorrhage or thrombosis. 
x\lcoholism in the parents is of some importance; also syphilis which 
leads to tissue changes about the vessels, and gives rise to endarteritis. 

2. Injuries at Birth. — Trauma from forceps, asphyxiation from a 
long and difficult labor, or premature birth may all bring about menin- 
geal hemorrhage. Usually, however, intra-uterine trauma or maternal 
syphilis precipitates premature birth. 

3. Causes After Birth. — Direct trauma to the head may cause 
hemorrhages. The most common postnatal cause, however, is 



CEREBRAL PALSIES 825 

encephalitis secondary to acute infections, such as measles, scarlet 
fever, whooping-cough, typhoid fever, tonsillitis, chorea, and endo- 
carditis. 

We distinguish two main types of cerebral palsies: 
(1) Infantile hemiplegia. (2) Cerebral diplegia, or Little's disease. 
In general it may be said that a difficult labor, premature labor, and 
asphyxia give rise to cerebral diplegia, whereas infections lead to 
hemiplegia. 

Pathological Anatomy. — The initial lesions are: (1) hemorrhage; 

(2) embolism; (3) thrombosis; (4) acute, and sometimes chronic, 
encephalitis. 

At a later stage, and as a result of these initial lesions, the following 
conditions are frequently seen: (1) porencephalia; (2) microgyria; 

(3) cysts; (4) patches of glial and connective-scar tissue; (5) local- 
ized sclerotic patches (tuberous sclerosis) ; (6) unilateral sclerosis of a 
portion of one cerebral hemisphere — cerebral atrophy. 

When the condition is the result of an inflammatory process, the 
meninges are usually thickened. 

Infantile Hemiplegia.— This form of palsy usually comes on after 
birth, either in consequence of a syphilitic taint or an encephalitis, 
but may occur either before or during birth. After the fifth year it 
is rare. 

Symptoms. — Although prodromal symptoms, such as headache, 
fever, vomiting, and general malaise may precede the onset, yet the 
disease usually sets in suddenly with fever, convulsions, and sometimes 
coma, followed by hemiplegia, which, however, may not appear for 
a week or more. Convulsions are usually on the same side as the 
paralysis. 

The paralysis in the beginning is a flaccid one, involving the face — 
its muscles and inferior branches — and the arm and leg. 

After eight to ten days the acute stage subsides, and the paralysis 
gradually recedes, and becomes spastic. Improvement takes place, 
especially in the face and leg. The face muscles may almost wholly 
recover merely showing weakness by mimetic and emotional con- 
tortions. The leg, too, may almost wholly recover, for on examination 
the only evidence of the former lesion may be exaggerated reflexes. 

The arm becomes spastic, and, in less favorable cases, the leg like- 
wise. The position that the arm assumes is characteristic. The 
upper arm is adducted, the forearm flexed and pronated, the wrist 
flexed, the thumb adducted, and the fingers flexed upon it. The leg, 
too, shows a spastic condition; it is rotated inward, and extended at 
the hip- and knee-joints, with plantar flexion of the foot — pes cavus. 
In walking the leg is dragged, and there is a circumduction like that 
seen in an adult hemiplegia When it walks the child makes accom- 
panying movements of the arm by raising it, and the faster the patient 
walks the higher the arm is lifted. 

Although the reflexes may be absent at the onset, they are always 
exaggerated. The Babinski, Oppenheim, and Gordon reflexes are 



826 THE NERVOUS SYSTEM 

present. Ankle and patella clonus may also be present. Aphasia 
may appear associated with either a right or left-sided lesion, but it 
usually soon disappears. Ataxia and intention tremors accompanied 
by voluntary movements are present, also involuntary, posthemiplegic, 
choreiform, and athetoid movements, as a result of which muscular 
hypertrophy takes place. 

Sensory disturbances and cranial nerve palsies are rare. At times 
there is atrophy of the optic nerve, hemianopsia, and rigid pupils, 
the latter usually associated with syphilis. 

Trophic disturbances of the muscles, skin, and especially of the 
bones, are common. The skin is cool and livid. There is muscular 
atrophy from lack of function. The changes in the bones are most 
important, the growth of the cranial bones being sometimes so affected 
as to produce marked asymmetry of the head and face. The long 
bones are especially involved, there is shortening of the affected arm 
and leg, and the growth of the bone is affected, especially its length, 
and the shortening is more at the distal than the proximal end. The 
circumference is also lessened, especially in the central portion. 

Epilepsy is a frequent complication, developing in more than one- 
half the cases. After the initial convulsion, the patient may remain 
free for days, months, or years before epileptic seizures appear. 

The mental development of the child may be normal; usually, 
however, some disturbance of intelligence is observed, and this may 
vary from mere feeble-mindedness to absolute idiocy. 

Cerebral Diplegia— Spastic Paraplegia — Little's Disease. — This type 
usually occurs either before birth or during delivery as the result of 
a difficult labor. Asphyxia neonatorum is the most frequent cause for 
hemorrhage. Trauma from forceps and hereditary syphilis are like- 
wise important. 

Symptoms. -*-In severe cases the disease is usually noticed soon after 
birth, the child's body and extremities, especially the legs, being rigid 
and spastic. In less severe cases this may not be observed until the 
time when the child should begin to walk, when, on putting it on its 
feet, marked rigidity of the extremities is noticed. The thighs are 
rotated inward, the knees cross and touch from contractions of the 
adductors, and the child stands upon its toes with its foot in complete 
plantar flexion. The contractions in the thigh involve the adductors 
and flexors, whereas the gastrocnemei are most involved in the lower 
leg. The arms are less affected, although the spasticity may be 
marked. 

When the upper extremities are involved, the arms are adducted to 
the body, the elbows are bent, the wrists flexed, the thumbs adducted, 
and the fingers flexed upon them. 

The muscles of the body generally are involved, giving rise to 
lordosis, kyphosis, and scoliosis. 

The gait is quite characteristic — the so-called "scissors gait. 1 " On 
attempting to walk the legs are crossed, the knees are pressed together 
and cannot be drawn apart, and the child walks on its toes. 



CEREBRAL PALSIES 



827 



Tremors and ataxia are common. Choreiform and athetoid move- 
ments are less frequent in this form than in the hemiplegic type! 

The deep reflexes of the involved area are greatly exaggerated. 
Ankle- and patellar clonus are present, as well as the Babinski, Oppen- 
heim, and Gordon reflexes. On the other hand, the extremities may 
be so rigid that no reflexes can be elicited. Trophic disturbances of 
the skin, muscle, and bones are usually not extensive. 





Fig. 84. — Feeble-minded, spastic para- 
plegia; male, aged six years. 



Fig. So. — Idiocy, spastic diplegia; male, 
aged four years. 



There may be cranial nerve palsies, nystagmus, strabismus, atrophy 
of the optic nerve, and inequality of the pupils. The face may be 
involved, and have a mask-like appearance. Dysarthria and brady- 
lalia are common, and are usually accompanied by impairment of- 
intellect. Esophageal spasm is sometimes observed, and causes 
difficulty in swallowing. 

Convulsions in the first few davs after birth are common; but 



828 THE NERVOUS SYSTEM 

epilepsy, which develops later, is not as frequent as in other types of 
palsy. 

The mental development of the child may be normal, although 
there is usually a defect in mentality varying from feeble-mindedness 
to idiocy. 

Diagnosis. — The diagnosis of cerebral infantile palsies is purely a 
clinical one, and can be made only by considering the history with 
special reference to the question whether or not the palsy is progres- 
sive, and there are any progressive brain symptoms. 

Cerebral hemiplegia, setting in acutely as an encephalitis, must 
be differentiated from meningitis, infectious fevers, infantile eclampsia, 
and poliomyelitis. The differentiation from the latter disease is no 
longer of much importance, for we now know that both the cerebral 
and spinal forms may coexist in the same patient, being known as 
encephalopoliomyelitis . 

Cerebral palsies must be differentiated from brain tumors of slow 
growth, from cerebral syphilis, multiple sclerosis, hydrocephalus, and 
Friedreich's ataxia. 

Prognosis.— Improvement may go on for years. The arms may 
almost completely recover, except for a slight permanent spasticity. 
Improvement also takes place in the lower extremities, for these chil- 
dren learn to walk, even if tardily; the mental calibre, too, often 
somewhat improves. They are always predisposed to intercurrent 
infectious diseases, to which they readily succumb. In the hemi- 
plegic form death may take place during the initial stage. Improve- 
ment is usually as great as in the diplegias. 

Treatment. — This is purely symptomatic, in order to maintain the 
proper nutrition of the parts involved, and depends upon the intelli- 
gence of the child, the extent of the paralysis, and the amount of 
deformity. 

The galvanic current should be applied to the affected muscle. 
Hydrotherapeutic measures, such as warm baths, tend to relax the 
muscle spasm. Massage, combined with passive movements, gym- 
nastic exercises, and Frenkel's movements are of special benefit in 
cases in which there is not too great impairment of the mentality. 

Braces may be necessary to prevent contractures, and various 
orthopedic operations — tenotomy and tendon transplantation — have 
been devised for their relief. 

Trephining of the skull with removal of the primary foci has been 
performed for the relief of epilepsy. The mental training of the child 
should not be neglected. 

IDIOCY. 

Synonyms. — Mental Deficiency — Imbecility — Feeble-mindedness. 

Children who have mental diseases may be divided into two classes : 
those who have physical defects in addition to the mental condition, 
and those in whom there are no physical defects. 

It is impossible to make a sharp differentiation between the various 



IDIOCY 



829 



types of mental defects in children, as the different forms blend into 
one another; but cretinism, Mongolian idiocy, and amaurotic family 
idiocy are types easily recognized. 

Imbecility and feeble-mindedness are terms applied to the minor 
forms of idiocy in which there is no extensive cerebral lesion. The 
backward child should not be placed in this class, for its retarded 
mental development is often due to some abnormal physical condition 
which can be corrected, such as defective sight or hearing. 

Etiology. — Idiocy may be either congenital or acquired. In the 
majority of cases which present physical defects, idiocy is congenital, 
and may be associated with defective brain development, as in poren- 
cephalia and agenesis corticalis, or with lack of development of the 
brain as a whole. 

Another class of cases is associated with internal or external hydro- 
cephalus, and microcephalic children furnish a certain number of 




Fig. 86. — Idiocy, male, aged five years. 



these cases. Consanguinity, injuries at birth, and syphilis are not 
uncommon causes of idiocy in children, and in many cases in which 
paralysis appears there is a history of meningeal hemorrhage or cere- 
bral hemorrhage of traumatic origin. 

Cretinism, cerebrospinal meningitis, and anterior poliomyelitis may 
also give rise to idiocy, and a certain proportion of epileptics become 
idiots as a result of brain lesions due to repeated epileptic seizures. 

As a rule, mental defects unassociated with physical abnormalities 
are not apparent until the second period of childhood, melancholia, 
mania, katatonia, and dementia being occasionally observed in older 
children. 

Although no definite time limit can be established for the manifes- 
tation of the various phases of mental function, yet in the normal 
infant there should be evidences of control of the senses of hearing and 
sight by the fourth month, later appreciable signs of memory, percep- 



830 THE NERVOUS SYSTEM 

tion, and power of attention, and the child should be able to recognize 
objects and familiar faces and be able to express pain and pleasure. 

At nine months some degree of understanding should be manifested 
when familiar words are spoken, and at this age the normal infant 
should begin to imitate spoken words, and attempt to creep about. 

When any of these functions is considerably delayed, the child 
should be carefully studied in order to determine accurately the extent 
of mental impairment. The family history and lives of the parents 
should be investigated for some possible etiologic factor, and an 
accurate history of the child's life from birth be secured. Special note 
should be made of any insanity, alcoholism, chorea, or hysteria in 
the family, and in the child's history convulsions shortly after birth, 
injuries at birth, eclampsia, and asphyxia are important points. 

Symptoms. — Both mental and physical symptoms accompany 
idiocy, although an idiot may resemble a perfectly normal child. 

Mental Stigmata. — Mental deficiency is rarely suspected in early 
infancy, except in the case of the Mongolian idiot, in whom we find 
abnormality of the features. When physical defects are present, 
they are usually noticed before mental abnormality is suspected, and 
in these cases the infant is brought to the physician because it cannot 
sit up, walk, or, perhaps, talk at the proper time. 

Upon examination it becomes evident that the child has no control 
of its limbs; saliva usually dribbles from its mouth; it has a vacant 
stare, or moves the eyes aimlessly, taking no particular notice of any- 
thing. The eyes should always be examined in these cases to determine 
whether or not there are any visual defects, such as microphthalmia, 
rederemia, coloboma iridis, lesions of the vitreous, congenital cataract, 
strabismus, or partial or central blindness of central origin. 

The sense of hearing may be defective or entirely absent from con- 
genital or acquired causes, and in idiots there is always imperfect 
development of the senses of taste and smell. The appetite is usually 
ravenous, but, as a rule, there is no particular preference as to food. 
There is also a remarkable degree of insensibility to pain, heat, and 
cold, and this in some cases may be so great that bodily injury, and 
even mutilations, self-inflicted, are not uncommon. 

Even when the sight is perfect, the idiot may not recognize its 
mother, shows no instinctive understanding of the nursing bottle, 
and at the age when it should be talking — one to two years — utters 
strange sounds and shrill cries, and makes no attempt to imitate 
spoken words. 

At the age of three or four years, most cases of idiocy can be recog- 
nized, for the children do not talk, their vacant expression is apparent 
to all but the mother, they are unclean in their habits, in defecating 
and urinating, and in temperament they are either amiably stupid, 
or irritable, excitable, and uncontrollable. 

Convulsions are not rare in idiots, and in the majority of cases they 
signify the presence of definite organic lesions of the central nervous 
system, such as are found in meningitic and syphilitic idiocy. 



IDIOCY 831 

Physical Manifestations. — The head may be either excessively large 
(hydrocephalic) or very small (microcephalic). The hydrocephalic 
head is familiar to all, with its rounded ball-shape, widest at the 
temples, and presenting a sharp contrast to the small face and tiny 
features. These children are usually dull and stupid, but not irritable, 
and they have a timid, shrinking, and sad appearance. 

The microcephalic idiot has a small head with low forehead, a 
poorly developed occipital prominence, closed fontanelles, and pre- 
maturely closed and ossified sutures; but, strange as it may seem, the 
small skull is in many cases independent of the poorly developed 
brain, and a child whose skull is normal may have a microcephalic 
brain. 

Even the microcephalic skull is usually larger than the brain 
requires, for there is a lack of development of either the whole brain 
or of the occipital, frontal, or parietal lobes. The eyes are small, 
the ears project, and the nose and lower jaw are large, so that the 
face seems quite large in proportion to the skull. In some cases the 
rest of the body may appear to be perfectly normal, while in others 
there is paralysis, either flaccid or spastic. 

True microcephalic idiots are obstinate, vulgar, and brutal. If 
the brain lesions are not extensive, they sometimes live past middle 
age, but the hydrocephalic infant rarely survives until the end of the 
first year. 

The syphilitic idiot usually presents the characteristic signs of 
syphilis, such as the bossed skull, saddle-nose, Hutchinson's teeth, 
rhagades, and congenital deafness. 

Howe, in a summary of 517 cases of idiocy, found the following 
physical defects: Deafness in 12, blindness in 21, and defects hi the 
nose or mouth, such as hare- lip and high palatal arch, in 23 cases. 
The condition of the extremities varies in the different types of idiocy. 
Howe found in 54 cases of this same series, deformities of the hands 
and feet, and in 96 cases there was paralysis of one or more limbs. 

Many hydrocephalic infants suffer with spastic paraplegia, the 
legs being affected, as a rule, while the upper extremities are but 
little involved. The paralytic idiot has either hemiplegia or diplegia, 
and contractures may become quite marked. In cretinism, micro- 
cephalic idiocy, and syphilitic idiocy there is manifest weakness of 
all the extremities. 

Among the other physical peculiarities which idiots occasionally 
present may be mentioned supernumerary or deficient fingers and 
toes, asymmetry, malformations, congenital dislocations, ankyloses, 
and numerous minor abnormalities. 

Diagnosis. — The diagnosis of idiocy is a matter of great importance, 
but can be positively arrived at only after accurate history taking, 
which in many instances will reveal the etiological factor, also after 
careful physical examination for the stigmata of degeneration, and an 
investigation of the mentality in which the patient's intelligence is 
compared with that of a normal child of the same age. Mentality 



832 THE NERVOUS SYSTEM 

slightly lower than normal may mean merely backwardness, but great 
deviations from the normal are in the majority of cases due to idiocy. 

Prognosis. — So far as complete recovery is concerned, the prognosis 
in idiocy is unfavorable; but surprising improvement often takes 
place, so that a case must not be pronounced hopeless unless there 
is some congenital defect of the brain, or there has been a hemorrhage 
at birth which caused paraplegia or diplegia. In cases which follow 
meningitis or encephalitis, the outlook is somewhat better than in 
those just mentioned, and even in cretinism and syphilis prompt 
therapeutic measures are not without good results. 

Treatment. — In all but the mildest forms of idiocy the children are 
far better off in institutions which will educate and train them by 
special methods than in their own homes; and, moreover, they 
should be kept apart from normal children. Special schools and 
training are necessary, too, for the backward child, if the best results 
are to be secured. The idiot who is tractable may be kept at home 
until the sixth or seventh year if there are no younger children to whom 
he may set a bad example. 

Moral degenerates and vicious and unclean idiots should be placed 
in institutions just as soon as they can be admitted. The problem 
of the mentally deficient child is an economic one, and experience has 
proven that many of these unfortunates may become self-supporting 
instead of being always a cost to the family or the State. 

AMAUROTIC FAMILY IDIOCY. 

This disease, which was first described by Warren Tay, in 1881, 
and later given its name by Sachs, of New York, is not a rare one. 
It is characterized by arrested cerebral development, by blindness, 
and by changes in the macula lutea, together with progressive impair- 
ment of the functions of the muscles. The affection shows a marked 
predilection for the Hebrew race, nearly all of the recorded cases 
having occurred among Jewish people. 

Etiology. — The etiology is most obscure, and it has not been defi- 
nitely determined whether the arrested development and degeneration 
are due to antenatal or postnatal causes. Many observers believe 
the affection to be toxic in origin, and it has also been attributed to 
syphilis and alcoholism in the parents. It is not uncommon for two, 
three, or four children in the same family to be affected. 

Pathology. — Postmortem investigations have shown degeneration 
of the ganglion cells throughout the entire nervous system. The 
cellular structures lose their identity, their nuclei being scarcely demon- 
strable, and the protoplasm markedly degenerated. Blindness in 
these cases is due to degeneration of the ganglion cells of the retina 
and of the fibers of the optic nerves and tracts. 

Symptoms.— The infant is apparently normal at birth, and may 
remain so until the sixth, or even the tenth month, when the parents 
usually notice that it makes no progress in development. At this 



MONGOLIAN IDIOCY 

age the child does not hold up its head, moves about very little, takes 
no interest in its surroundings, and does not even follow objects with 
its eyes. But, unless an ophthalmic examination is made, blindness 
may not be suspected, although the eyes have a peculiar and fixed 
stare. Nystagmus may be present but is not pathognomonic. 

The child now begins to retrograde, instead of progressing, and by 
the end of the first year optic atrophy and paresis may be complete. 
The muscles are absolutely without power, and the little one can 
neither sit up nor hold up its head. At first there is flaccidity, later 
rigidity and spasticity of the muscles, and occasionally convulsions. 

Mental retrogression is also noticeable, and the child fails to recog- 
nize familiar objects and faces, but is unusually susceptible to sounds, 
starting violently at each sudden noise, such as the slamming of a 
door or clapping of the hands. Eventually it becomes dull, apathetic, 
totally indifferent to its surroundings, and has no power to change the 
position of its limbs. Progressive emaciation renders the child help- 
less, and a pitiable object of mere skin and bone. 

In some cases swallowing becomes impossible, and gavage is neces- 
sary. Death usually occurs in about a year after the onset, and is 
due to marasmus, exhaustion, or hypostatic pneumonia. 

Prognosis. — The disease comes on slowly, and its course is marked 
by gradual but progressive mental and physical degeneration, and an 
invariably fatal termination. 

Diagnosis. — As a rule the diagnosis is readily made from the signs 
and symptoms. The findings on ophthalmic examination are pathog- 
nomonic. 

Treatment. — Treatment is never curative, but under judicious 
management the life of these infants may be prolonged for a year or 
more, although death is inevitable. 

MONGOLIAN IDIOCY. 

The Mongolian type of idiocy occurs only in the Caucasian race, 
and is characterized chiefly by a Mongolian, or Chinese, cast of face, 
also by a microcephalic skull and retarded growth of the bones. 

Etiology. — This form of idiocy is congenital, and in the majority 
of cases it will be found that both parents were past middle age when 
the child was born, but nothing further is known of its etiology. 
The disease appears with equal frequency in all classes of society. 
There is usually but one case in a family. 

Pathology. — The brain is smaller and lighter in weight than normal, 
the fissures are defective, and there is evidence of faulty development 
of the cortex. Usually there are abnormalities of the palate, ears, 
and fingers. Malformations of the heart, such as incomplete ventricu- 
lar septum and patent ductus arteriosus, are not uncommon, although 
malformations of other viscera are rare. 

Symptoms. — In early infancy, the facial expression and backward- 
ness in physical development are the only noticeable signs. The 
53 



834 



THE NERVOUS SYSTEM 




Fig. 87. — Mongolian idiocy; child aged twenty months. 




Fig. 88. — Mongolian idiocy; patient aged nine months. 



MULTIPLE NEURITIS 835 

head is flattened from before backward, the fontanelles remain open 
longer than usual, the nose is broad and flat, and the eyes are more 
widely apart than normal, are prominent, and slant obliquely, so that 
the palpebral fissures extend upward and elevate the outer eanthus. 

The peculiarities of the face in these cases, together with mouth 
breathing and the abnormally large tongue which protrudes from the 
open mouth, often make one suspect cretinism; but the skin is soft 
and velvety in the early stages, and the hair neither dry nor brittle. 

Adenoids are sometimes thought of as a cause of the mouth breath- 
ing; but this is due to narrowing of the nasopharyngeal vault pro- 
duced by anteroposterior narrowing of the skull and prominence of 
the upper cervical vertebrae, all of which can readily be appreciated 
by making an examination for adenoids. The hands are short, the 
little finger is also short, and frequently curves inward over the ring 
finger. Abnormalities of the bones of the hands and wrists are demon- 
strable by .r-ray examination. 

The muscles of the body are flabby, and the joints all show evidences 
of preternatural mobility. Growth is very slow, and mental develop- 
ment markedly retarded. Dentition is delayed, the teeth usually 
not appearing until the fourth or fifth year when the child can walk 
and talk. 

Prognosis. — There are mild, moderate, and severe cases of Mongolian 
idiocy. The severe cases usually die in early childhood and before 
they are three years old; those moderate in degree may live past 
puberty, and do fairly well in institutions; while a few of the mild 
type gradually improve mentally until they show a fair amount of 
intelligence, and may reach adult life. 

Diagnosis. — The facial expression of the Mongolian idiot is so 
characteristic that a mistake in diagnosis is most unlikely. Other 
diagnostic points are the shortness and incurvation of the little finger 
and the extreme flexibility of the joints. Mongolian idiocy may some- 
times be mistaken for cretinism; but thyroid therapy has no effect 
on the Mongolian idiot, and close examination of these children reveals 
other differential points, such as the slanting eyes, the condition of 
the hair and skin, and the absence of myxedema. 

Treatment. — There is no medical treatment that exerts any influence 
on the affection. Massage, fresh air, and careful regulation of the 
diet, combined with the best possible hygienic conditions, are of 
benefit in maintaining the child's health and strength. 



DISEASES OF THE NERVES. 

MULTIPLE NEURITIS. 

Multiple neuritis, except the postdiphtheritic form, is a very rare 
disease in childhood. It is either secondarv to certain infections, 



836 THE NERVOUS SYSTEM 



diseases and poisons, or may occur as an idiopathic disease. Its most 
frequent cause is diphtheria, which gives rise to some form of neuritis 
in from 5 to 12 per cent, of all cases. In addition, multiple neuritis 
has developed after typhoid fever, and, more rarely, after scarlet 
fever, measles, malaria, influenza, erysipelas, chicken-pox, pneumonia, 
and tonsillitis. Of the poisons, alcohol, phosphorus, arsenic, and lead, 
all produce neuritis, but these forms are seldom seen in childhood. 

Diphtheritic Paralysis. — Diphtheritic paralysis is a frequent com- 
plication of diphtheria, and is estimated variously at between 5 to 
12 per cent, of all cases. This proportion is thought to have been 
increased by the use of antitoxin. It must be remembered, however, 
that the death rate of the disease has diminished, and that many 
children who previously would have died from a severe form of diph- 
theria are now saved by antitoxin, and these cases may later show 
paralysis. Unless the serum is administered very early it will have 
little effect, as it does not seem to give the same protection to the 
nervous system as to the rest of the body. Neither does the severity 
of the infection modify greatly its frequency; for, although most 
commonly observed in the severe types, yet it often occurs after mild 
infections. In fact, the paralysis may sometimes be the first sign of 
diphtheria, the throat symptoms having been so mild as to have 
escaped notice. Paralysis usually sets in two to three weeks after 
the disease has subsided, although it may develop during its course. 

Pathological Anatomy. — The most extensive pathological changes 
are found in the peripheral nerves. These changes may be both 
interstitial and parenchymatous, the latter being the most pronounced. 
There are degeneration of the parenchyma and inflammation and 
proliferation of connective-tissue cells which cause cylindrical and 
fusiform swellings on the trunks of the nerves, appearing most fre- 
quently on the smaller nerves in the muscles and skin. Similar degen- 
erations have been observed in the cranial nerves, as well as inflam- 
matory changes in the gray matter of the spinal cord, and hemorrhages 
and hyperemia in the white matter and spinal ganglia. 

Symptoms. — The paralysis is quite variable. It may either be 
limited to isolated groups of muscles or more generalized, involving 
numerous spinal and cerebral nerves. 

Three different forms of the affection may be distinguished. In 
the early and milder form, paralysis of the soft palate develops first, 
often making its appearance during the acute stage of the disease 
following the angina; or it may not appear until one to three weeks 
have elapsed. The speech becomes nasal in tone, and unintelligible. 
On attempting to swallow fluids, some is regurgitated through the 
nose, and the ingestion of solid food is markedly impeded. Upon 
examination the soft palate is seen to be flaccid, immobile on phonation, 
and exhibiting with difficulty a reaction of degeneration. Most 
frequently there is anesthesia of the mucous membranes, with corre- 
sponding absence of the pharyngeal reflex. 

The paralysis may extend, and involve the deep pharyngeal and 






MULTIPLE NEURITIS 837 

laryngeal muscles. In consequence of the failure of the epiglottis to 
close during deglutition, of the anesthesia of the mucous membranes, 
and of the regurgitation of food through the nose, there is great 
danger of aspiration of food into the larynx, giving rise to fatal bron- 
chopneumonia. With involvement of the recurrent laryngeal nerve 
there is hoarseness, or even aphonia. 

The vagus fibers supplying the heart may be suddenly affected and 
cause a slow pulse (rare), or, more frequently, arrhythmia and a 
rapid pulse rate, due to paralysis of the depressor fibers. Sudden 
death may ensue from this cause. In other cases the paralysis may 
extend to the eyes, involving bilaterally the ciliary muscles, causing 
inability to accommodate the eye, to read, or to do any fine work. 
The reaction to light and to accommodation is, however, usually 
present. Other ocular palsies are rare. The abducens paralysis is 
the most frequent; the oculomotor or trochlear the least common. 
The deep tendon reflexes of the lower extremities may be lost early in 
the disease. In a few cases they may be exaggerated with an ankle- 
clonus. 

In the second form— the more severe type — the involvement is 
more general, extending to the extremities either as ataxia or as true 
palsy with sensory disturbances. Ataxia appears about four weeks 
after the paralysis of the soft palate. The gait becomes ataxic, and 
Romberg's sign can be elicited. The deep reflexes are abolished, but 
in this form there is no paralysis in the extremities; in fact, the 
muscular strength may be perfectly normal. Paresthesias are com- 
plained of; but sensory disturbances, except loss of muscle sense, are 
usually not pronounced. 

In the third, or most severe form, there are extensive atrophic 
flaccid palsies with a positive reaction of degeneration. The muscles 
of the neck, the trunk, the intercostals, and the diaphragm may like- 
wise be involved. Paralysis of the phrenic nerve gives rise to cyanosis 
and severe dyspnea which may suddenly cause death. The breathing 
becomes Cheyne-Stokes in type, accompanied by rapidly increasing 
edema of the lungs. This is the most common cause of death, the 
mortality being 76 per cent, in 33 cases collected by Ross. 

A facial palsy has also been observed; sensory disturbances are 
quite marked; hyperesthesias and anesthesias are extensive. Bladder 
and rectal disturbances are rarely present. Trophic disorders of the 
skin may appear. In grave cases, marked mental depression has 
been observed. 

Course and Prognosis. — The course of the disease is usually a favorable 
one, and ends in complete recovery. Paralysis of the vagus and phrenic 
nerves, aspiration pneumonia, and general inanition are to be feared, 
and may be rapidly fatal; but all danger to life is generally past after 
six to eight weeks. The paralysis of the soft palate and accommo- 
dation recedes, and at the end of three or four months the symptoms 
have usually all cleared up. Occasionally some remains of the 
paralysis, especially of the extremities, will persist for from eight 



838 THE NERVOUS SYSTEM 

months to a year. Complications, such as nephritis and endocarditis, 
make the prognosis more grave. 

Treatment. — In the majority of cases of postdiphtheritic paralysis, 
the treatment consists of general tonics and palliative measures. 
When the paralysis has progressed beyond simple paralysis of the 
soft palate, absolute rest in bed should be ordered, and all possible 
strain upon the heart prevented. The paralysis may be so extensive, 
and the danger of aspirating food into the larynx so great, as to neces- 
sitate feeding by gavage. The tube can be passed either through the 
mouth or the nose. Usually from 8 to 10 ounces of food can be given 
at intervals of four to six hours. If sufficient nourishment cannot be 
administered in this manner, and the nutrition suffers, nutritive 
enemata may be required. Cracked ice should be given to relieve 
the thirst. 

Medication. — Of drugs, strychnine is the most beneficial. It should 
be administered hypodermically at three-hour intervals in doses of 
-g-g-0- of a grain for a one- to two-year-old child; from -g-J-g- to T ^o" 0I * a 
grain for a two- to four-year-old child; from -^ho to y^-g- of a grain 
after the fourth year. If strychnine can not be used hypodermically, 
tincture of nux vomica may be given in corresponding doses. For 
rapid heart action and restlessness, small doses of tincture of strophan- 
thus combined with codein are indicated. To ward off threatened 
cardiac paralysis, morphine should be administered hypodermically 
together with strychnine. When respiratory paralysis seems imminent, 
artificial respiration should be instituted together with the giving of 
strychnine. In these severe cases, large doses of diphtheria antitoxin 
have appeared to have some beneficial results. 

In the acute stage all hydrotherapeutic measures are contraindi- 
cated. When, however, the paralysis begins to recede, electricity, 
massage, and mechanotherapeutical procedures should be begun. 
Mild galvanic stimuli should be applied to the extremities and the 
soft palate. Frenkel's exercises should not be begun until after the 
heart has fully recovered. 

Multiple Neuritis, Postinfectious (Non-diphtheritic). — Other infec- 
tions which, as we have seen, may give rise to paralysis, are typhoid 
fever, in rare cases scarlet fever, measles, influenza, malaria, erysip- 
elas, chicken-pox, pneumonia, tonsillitis, tuberculosis, and syphilis. 
Neuritis following these infections is characterized by paraplegia, 
either limited to the peroneal group of muscles or, in some cases, to 
the thigh, or it may extend to the arms, giving rise to paralysis of 
both arms and legs, in which, however, there is no predilection for 
the group of muscles supplied by the radial nerve. 

Palsies of the vagus, so characteristic of the diphtheritic form, rarely 
occur. As the disease progresses in the peroneal group of muscles, 
there is resulting weakness which subsequently produces foot-drop. 
On walking there is the typical "steppage-gait." The paralysis may 
be confined to this group of muscles or may extend to the thighs and 
arms. Involvement of the muscles of the trunk is rare. There is 



FACIAL PARALYSIS 839 

resulting loss of reflexes, both superficial and deep, in the involved 
area, a positive reaction of degeneration, and muscular atrophy. 
Sensory disturbances are marked. Hyperesthesia and anesthesia 
are complained of. Trophic disturbances are sometimes observed. 

Multiple Neuritis, Toxic. — Alcoholic Neuritis. — This is exceedingly 
rare in children. Only a few cases have been collected from the 
literature. The course of the disease is similar to that in the adult. 

Lead Neuritis. — Neuritis due to lead poisoning is more frequently 
observed in children than alcoholic neuritis. The children become 
exposed to lead through drinking cups and toys. The course of the 
disease differs but little from that in the adult, except that the peroneal 
muscles of the legs are first attacked, and this gives rise to foot-drop. 
The arms are later involved, the distribution being that of the radial 
nerve, then the extensors of the fingers and hand. The paralysis is 
a flaccid one, with loss of reflexes, a positive reaction of degeneration, 
and muscular atrophy. There are no sensory disturbances. Bladder 
and rectal disturbances are negative. 

As in the adult, lead colic is frequently complained of. Anemia 
and the lead line are often present. Encephalitis with convulsions, 
hemiplegia, and optic neuritis have all been observed. 

The prognosis is good if the poison can be completely eliminated. 

Arsenical Neuritis. — This type of neuritis has occasionally followed 
the administration of Fowler's solution in the treatment of chorea and 
other maladies. 

It is characterized by symmetrical atrophic palsy of the arms and 
legs which develops rapidly, and is accompanied by neuralgic pain 
and hyperesthesia. In the legs the peroneal group of muscles are 
especially apt to be involved; whereas in the arms it is the muscles 
supplied by the radial nerve. The nerves and muscles are painful on 
pressure. There are muscular atrophy, an absence of reflexes, and a 
reaction of degeneration. Trophic disturbances of the skin — hyperi- 
drosis, glossy skin, and pigmentation — are quite characteristic. 

FACIAL PARALYSIS. 

The facial nerve may be affected anywhere along its course, either 
within the cranium, within the bony canal, or after its exit from the 
cranium. Obstetrical facial palsy, which results from injury to the 
nerve at birth, either by pressure of the forceps or some obstacle to 
the passage of the head through the pelvis, has already been described 
(see page 111). 

Other etiological factors involving the portion of nerve peripheral 
to the exit from the cranium are cold and exposure to dampness as 
seen in the rheumatic type, the pressure of enlarged lymphatic glands, 
mumps, and trauma, such as a severe blow on the ear, or following 
operations on glands or tumors at the angle of the jaw. A common 
cause is an inflammation of the nerve within the Fallopian canal 
produced by disease of the middle ear. This is seen most frequently 



840 THE NERVOUS SYSTEM 

after chronic otitis media, especially when there is caries of the 
petrous portion of the temporal bone, due very commonly to tuber- 
culosis. 

Intracranial diseases, such as basilar meningitis, tumor, or a fracture 
of the skull, may occasionally give rise to facial palsy. The paralysis 
following these intracranial lesions is usually complicated by other 
basal palsies and cerebral symptoms. The auditory nerve is also 
likely to be affected. 

Symptoms. — The symptoms depend upon the portion of the nerve 
affected. If the involvement is peripheral, there is paralysis of all the 
muscles on one side of the face, including those of the forehead and 
those about the eye. The affected side of the face becomes flaccid, 
in consequence of which the mouth is usually drawn toward the 
unaffected side. The face is smooth; the nasolabial fold is obliterated; 
the child is unable completely to close the eye (lagophthajmus) . 
Any voluntary movement of the side of the face involved is impos- 
sible. 

There is inability to wrinkle the forehead, to pucker the lips, to 
contract the eyebrows, to whistle, or to puff out the affected cheek. 
Nursing and mastication are interfered with. If the paralysis is 
complete there is difficulty in deglutition and articulation. Inequality 
of the face is evident when the muscles are brought into action, as in 
laughing or crying. Sensory disturbances do not appear. The elec- 
trical reactions depend upon the extent of injury, varying from 
diminished electrical irritability to a reaction of degeneration. 

If the involvement be within the bony canal, and is the result of a 
previous middle-ear disease, there is usually a history of discharge 
from the ear and some deafness. The symptoms are the same as 
those mentioned above from peripheral involvement. As the chorda 
tympani is given off within the canal there is, in addition, a dis- 
turbance of the sense of taste in the anterior third of the tongue, 
together with a diminution of the salivary secretion. If the involve- 
ment be intracranial, due either to a basilar meningitis, a tumor, or 
a fracture, the auditory nerve is usually similarly involved, and in 
addition there are cerebral symptoms. If the lesion is central and 
above the nuclei of the seventh cranial nerve, the superior branch 
innervating the muscles of the forehead usually escapes, the elec- 
trical reactions are normal, and there are generally paralyses of the 
extremities. 

Prognosis. — In the rheumatic form, as a rule, recovery takes place 
in several weeks or months. In palsies due to middle-ear disease the 
outlook is less favorable, and permanent paralysis is likely to result 
in muscular contractions which give rise to spasms and twitchings. 
With respect to palsies which are caused by intracranial involvement, 
the result depends upon the etiological factor. 

Diagnosis. — In the majority of cases, the diagnosis of facial paralysis 
offers no difficulty. To get a clear conception of the_case, its cause, 
the location of the lesion, and the extent of the involvement must be 



CHOREA 841 

determined. It is also highly important to differentiate between a 
peripheral lesion and a central one above the pons. 

Treatment. — The treatment depends upon the causative factor. 
In the rheumatic form, hot applications, local bleeding from behind 
the ear, and blistering are extremely beneficial, in conjunction with 
the administration of the salicylates. When due to ear disease, appro- 
priate local treatment should be begun, and massage and electricity 
resorted to in all stubborn cases. 

CHOREA. 

Synonyms. — St. Vitus' Dance — St. Anthony's Dance — Sydenham's 
Chorea — Chorea Minor. 

Definition. — Chorea is an affection of the nervous system, charac- 
terized by incoordination and paresis of the muscles of the body, 
and by a tendency to cardiac complications. Involuntary muscular 
movements, twitchings, and emotional instability are among the 
prominent features of the disease. It is now regarded as infectious, 
and may occur sporadically or in epidemics. 

Many varieties of chorea have been described, grouped according 
to the prominence of one or more special symptoms. Among these 
may be mentioned chronic progressive chorea, chronic adult chorea, 
chorea major, congenital and senile chorea, posthemiplegic chorea, 
chorea gravidarum, and choreic insanity. Dubini's disease, or elec- 
tric chorea, is a form marked by sudden spasms. 

Etiology. — The specific organism which produces chorea is unknown; 
but because of the frequent association of this disease with rheumatism, 
and the tendency to cardiac complications which it exhibits, it is 
believed to be closely allied to the microorganism which causes rheu- 
matism. This close association of the two diseases is shown in the 
following summary, given by Fischer, of cases that have been reported. 

Of Steiner's 252 cases, 4 suffered from rheumatism; of Sachs' 70 
cases, 6; of Sinkler's 279 cases, 37; of Crandall and Holt's 146 cases, 
63; and of Fischer's 100 cases, 25. 

There is also in these cases a marked tendency to tonsillitis, and in 
a large majority of instances of chorea we find hypertrophied and 
diseased tonsils, all of which serves to link rheumatism and chorea 
closer together, and to lead to the suspicion, or belief, that the 
infecting organisms which produce these diseases gain entrance to the 
system via the tonsils. 

Fright and nervous shock have been thought to play an important 
part in the etiology of chorea; but it seems more probable that these 
should be regarded as immediately exciting causes rather than predis- 
posing factors. In epidemics, especially those occurring in institutions, 
imitation may be responsible for a certain number of cases, but only 
as an exciting factor. 

Among other causes leading to chorea may be mentioned overwork 
at school, reflex * irritation from pruritus, adenoids, polypi, phimosis, 



842 THE NERVOUS SYSTEM 

eye strain, intestinal parasites, and menstrual disorders. Heredity 
is another important predisposing factor, and in many cases the child's 
neurotic tendencies can be traced to neuropathic parents, or we find 
a family history of gout, rheumatism, tuberculosis, or other constitu- 
tional dyscrasia. Chronic malaria, anemia, and chronic gastro-intes- 
tinal disturbances are common findings. Masturbation is practised 
by many of these children, and the habit is frequently a forerunner 
of the disease. 

One of the most marked characteristics in the etiology of chorea 
is sex, for girls are affected twice or even three times as often as boys. 
In a series of cases reported by Sinkler, 232 of 328 were in females. 
Chorea is especially common from the seventh to the fifteenth year, is 
rare before the third year, is practically never seen in infants, and in 
adults, as a rule, is observed only in pregnant women. 

In the eastern part of the United States the majority of cases 
occur in the spring months, and fewest in the early winter, the seasonal 
curve corresponding to that of rheumatism. Chorea is most common 
among Russian Jews, and rare among negroes. 

Pathology. — The pathology of chorea has not been determined, 
and there is at present great diversity of opinion on this subject. 
It is obvious that there can be no extensive or permanent lesions in 
the nervous system, because complete recovery usually ensues a few 
weeks after the onset of the affection. The process is probably toxic 
in nature, and affects the central nervous system, especially the motor 
cortex about the Rolandic area. 

It is reasonable to assume that in those cases associated with rheu- 
matism, and in which there is cardiac involvement, the same toxin 
which affects the nervous system also damages the heart. In fatal 
cases, the diplococcus of Poynton and Paine has been isolated from 
the pia mater, and in those fatal cases associated with endocarditis, 
capillary emboli were found in the brain. Few cases, however, show 
any pathological lesions, and no constant or permanent changes have 
been found in the cases which have been studied postmortem. 

Symptoms. — The manner of onset in chorea is very variable, and 
an attack may be preceded by a prodromal period of several days or 
even a week. As a rule the disease comes on gradually, the child 
being at first a little more "nervous," irritable, and fretful than 
usual, and crying on the slightest provocation. Restlessness at night 
and slight twitchings during the day may be observed, also awkward- 
ness and clumsiness, especially in handling objects. Spoons, pencils, 
and books are unaccountably dropped, and the child is scolded for 
carelessness. It becomes increasingly difficult, and later impossible, 
for the patient to use its tumbler, knife and fork, pencil and pen, or 
to dress, most of all to execute fine movements, such as buttoning the 
clothes. Other delicate movements, such as threading needles or 
sewing, are also impossible, and the child frequently trips and 
stumbles. 

Following these symptoms the unmistakable signs of the disease 



CHOREA 843 

are usually recognized, the boy or girl exhibiting awkward involun- 
tary and irregular muscular movements, which are intensified by any 
effort on the part of the child to control them. These incoordinate 
jerking muscular contractions, which may involve all or any part 
of the body, constantly take place while the patient is awake, but 
involve alternately various groups of muscles, and cease only when 
the child is sound asleep. The muscles of the hands, arms, legs, and 
face are the ones most commonly affected, and the tongue may 
become involved to such an extent as to interfere with speech. 

These movements are never rhythmical or symmetrical, and one 
extremity may be affected to a greater extent than its fellow. The 
usual order of involvement is first the right arm, left arm, right leg, 
and left leg. When the shoulders are affected they jerk up and down, 
the arms rotate from side to side or swing backward and forward, 
the hands are flexed, extended, pronated, and supinated in turn, 
while the fingers are rigidly contracted and bent, rendering the child 
unable to hold anything. 

The lower extremities may be involved to such an extent that the 
child can neither sit, stand, nor lie still, and in severe cases it must 
be restrained to prevent it from injuring itself. The face may assume 
a number of expressions, and is constantly distorted. A systolic heart 
murmur is frequently heard, and at the height of an attack the pulse 
may be arrhythmical, and the respirations irregular. 

As a rule the choreiform movements extend to all parts of the 
body, but in 25 to 33 per cent, of the cases they are limited to one 
side of the body, the other manifestations of the disease being just 
the same as when all of the muscles are involved. Hemichorea is, 
however, usually regarded as more serious, because it is often asso- 
ciated with paresis of the affected extremities, also with psychical 
complications, such as melancholia and hallucinations. 

In all cases of chorea there is weakness of the muscles, yet exhaus- 
tion is rare, and the child does not complain of being tired. This 
paretic state of the muscles can readily be demonstrated by asking 
the patient to grasp the examiner's hand. To test for incoordination 
the child should be told to extend the arms outward, and then to touch 
the tip of the nose with each index finger alternately, or to bring the 
tips of the index fingers together quickly after the arms have been 
extended outward. 

The facial muscles may be so affected that the brow cannot be 
wrinkled, the eyes kept shut, or the tongue held out for more than a 
few seconds. In severe cases the child is unable to walk, talk, chew, 
or control the bowels and bladder; it appears to be paralyzed, and 
presents a pitiful spectacle. 

There is, as a rule, well-marked secondary anemia in chorea. The 
urine usually contains an excess of uric acid. Herter has demon- 
strated the presence of hematoporphyrin in the urine — in both chorea 
and rheumatism. Heart murmurs are frequently heard; and, while 
some of them may be of anemic origin, the majority are, unfortu- 



844 THE NERVOUS SYSTEM 

nately, due to intercurrent endocarditis, being diastolic or apical- 
systolic in time. Pericarditis may also appear as a complication of 
chorea. 

There is marked disturbance of nutrition, and the appetite is usually 
impaired. Pain is not uncommon, and in many cases is of rheu- 
matic origin. The mental state of these patients varies. At the 
onset there is hyperexcitability and irritability, later the children 
become emotional, laughing or crying upon slight cause. In very 
severe cases, melancholic or maniacal symptoms may develop. Unless 
complicated by rheumatism or endocarditis, there is no elevation of 
temperature in chorea. 

Diagnosis. — The diagnosis is readily made, and is based upon the 
characteristic, sudden, irregular, involuntary, and spasmodic move- 
ments of the body and on the abnormal movements of the tongue. 
Habit spasm may sometimes simulate chorea; but in habit spasm 
the movements are to some extent under the control of the will, while 
any attempt to control choreiform movements will only exaggerate 
them. Hemiplegia may be simulated by the pseudoparalysis in chorea; 
but chorea may be ruled out by the absence of spasticity and increased 
reflexes. 

Choreic movements are sometimes associated with infantile cerebral 
palsies; but true chorea can here be excluded because of the increased 
reflexes and spasticity which accompany infantile cerebral palsies. 
Imitative choreiform movements are of short duration, and in hyster- 
ical chorea the movements are to a certain extent purposeful, not so 
irregular as in true chorea, and other symptoms of hysteria are 
demonstrable. 

Course and Duration. — Chorea is a self-limited disease, and, if 
untreated, usually ends in recovery in from six to ten weeks. The 
active symptoms yield in about four weeks; but the condition of the 
child's nervous system influences both the course and duration, and 
in a few cases chorea may last for six months, or become chronic and 
persist indefinitely. In other cases only certain local spasms may 
continue for a long or short time. The intensity of the attack has 
apparently no effect on its duration, and many severe cases under 
careful treatment recover within the usual time. 

Prognosis. — In the cases without cardiac involvement, the prognosis 
is uniformly good, and complete recovery the rule; but relapses are 
quite common, and render the prospect of permanent recovery rather 
unfavorable. Relapses are most common in the spring following the 
first attack, and some children have an attack every year for three 
or four years in succession. The outlook is serious in all cases asso- 
ciated with delirium and prostration, as well as in those cases compli- 
cated by cardiac lesions. 

Treatment. — Since chorea is known to occur in epidemics, it is wise 
to isolate the child affected from other children, and especially is this 
advisable in boarding schools, asylums, hospitals, and other institu- 
tions where the inmates are closely thrown together. This measure 



CHOREA 845 

is particularly important in the case of girls between the ages of seven 
and fifteen, when they are most susceptible to the affection. 

The management of a case of chorea depends to some extent upon 
the severity of the attack; but in any case the general care of the 
patient is of quite as much, if not of more, importance than the 
administration of drugs. Rest in bed for two to four weeks is neces- 
sary in severe cases, and restraint may be required to keep the patient 
from falling on the floor. 

The child's room should be sunny and airy. All excitement should 
be avoided, and no visitors should be permitted in the room; but the 
patient may be allowed to play with a few toys, and the attendant 
should endeavor to amuse and entertain it in a quiet way. After the 
coarser movements have ceased, the child may be allowed to sit up 
and go about the room for a little while each day, gradually increasing 
the time spent out of bed as improvement sets in. 

If there is any evidence of cardiac involvement, rest in bed should 
be enforced for a longer period, and the patient should not be allowed 
to sit up until the physician feels assured that the lesion is a per- 
manent one. After the child is out of bed, a reasonable amount of 
outdoor life should be advised, but the mother or nurse must be care- 
ful not to let the patient become fatigued, either physically or men- 
tally. It is a good plan to have these children take one or two naps 
during the day. 

Even in very light cases the child should be taken out of school, 
and it should never be subjected to ridicule or any punishment. Play- 
ing with other children should be prohibited until some time after 
convalescence. Exciting books, games, and pictures should be for- 
bidden, and an effort made to surround these children with a quiet 
but interesting environment. Sometimes it is necessary to take the 
child away from home for awhile, particularly an older child. 

In severe cases, hospital treatment and care are usually more bene- 
ficial and satisfactory than home management. Cold douches or 
warm baths and massage daily are of advantage in chorea, and some 
authorities recommend a daily colonic flushing. 

The diet should be a bland one, the food depending upon the age 
and digestive capacity of the child. Milk is one of the best articles 
of diet for these children, and cereals, weak broths, chicken, cooked 
fruits, and fresh vegetables may be given. Tea and coffee, rich soups, 
sweets, pastries, and other indigestible foods should be prohibited. 

The two best drugs in chorea are iron and arsenic; but in the rheu- 
matic cases the salicylate of soda, in 10-grain doses, combined with an 
equal dose of bicarbonate of soda, three t'mes daily, is most 
effectual. 

Arsenic is given three times a day in the form of Fowler's solution, 
beginning with 2 or 3 drops in plenty of water after meals, and 
increasing the daily dose by 1 drop until 9 to 15 drops are taken three 
times a day, unless gastro-intestinal disturbances, puffiness under 
the eyes, and headache appear, when the arsenic should be imme- 



846 THE NERVOUS SYSTEM 

diately stopped for a few days, then resumed in small doses as before. 
It is never wise to give more than 15 drops three times a day, and this 
maximum dosage should be kept up for only a few days, and then 
gradually diminished to 5 drops three times a day. 

In many cases arsenic lessens the severity of the symptoms and 
shortens the attack; but, if there are no appreciable results after two 
or three weeks of its administration, it might as well be discontinued. 
The urine should frequently be examined while Fowler's solution is 
being given, and, should albumin appear, the arsenic should be 
immediately stopped. 

Iron may be given in the form of the citrate, J to 1 grain, or in one 
of the various preparations, such as the peptomangan (Gude's), 1 dram, 
or J grain of ferri sulphatis, three times a day after meals. Chloral, 
grains 1 to 3, or veronal or trional, grains 3 to 5, may be given once 
or twice daily to older children for their sedative effect. 

In severe cases morphine sulphate, -£$ to y^- of a grain, hyoscine 
hydrobromate, -^-Jr to y^ of a grain, or chloral hydrate, 5 to 10 grains, 
may be necessary to quiet the patient. Antipyrine, 15 to 20 grains 
daily, and strychnine sulphate, -£$ of a grain three times a day, are 
useful in some cases. Some children respond well to the sedative effect 
of sodium bromide, 3 to 5 grains every three hours. The bowels should 
be regulated by dram doses of magnesium sulphate, or J- to 1-dram 
doses of aromatic fluid extract of cascara sagrada. 

In cases of rheumatic origin it is wise to confine the treatment to 
antirheumatic lines, giving sodium salicylate or aspirin in 5-grain 
doses four times a day, and restricting the diet accordingly. 

The treatment which a child receives during convalescence from 
chorea is of the utmost importance because of the marked tendency 
to relapse, especially during the spring months. Work in school 
should not be resumed for several months after recovery, and these 
children should be sent to the country or seashore to recruit. 

The diet should be very nutritious, the warm or cold baths should 
be continued, and mild exercise indulged in. The anemia should be 
combated by the use of cod-liver oil, J to 1 dram, or the syrup of 
ferrous iodide, 5 to 20 drops, three times a day after meals. 

Any source of reflex irritation, such as eye strain, hypertrophied 
tonsils and adenoids, or phimosis, should be removed. For children 
who are subject to recurrent attacks of chorea, courses of the salicyl- 
ates or of Fowler's solution are advisable during the periods of appa- 
rently complete recovery. Rheumatic cases subject to relapses some- 
times remain free from attacks indefinitely if removed from a damp, 
cold climate to a warm, dry one. 

TETANY. 

Tetany is a motor neurosis, marked by persistent or intermittent, 
and more or less painful, spasms of the muscles of the upper and lower 
extremities. It is a condition rather than a disease, and is believed 



TETANY 847 

to be a symptom of several different affections. Most cases occur 
in the spring. 

Forms of the Disease. — Tetany may occur in either adults or chil- 
dren, and in Australia it has been observed in epidemics. There is 
also a surgical form. In attempting to classify the malady according 
to symptoms, we find one group of cases in which the muscular con- 
tractions are persistent, and another in which they are intermittent. 

Etiology. — The affection is not so common in America as it is in 
Austria and Sweden, and some other parts of the world; but it is 
probably more frequently met with in this country than is generally 
supposed. The majority of cases occur in infants between the third 
month and the second year. It is less common during later childhood, 
and is rarely seen in adults. Children of the poorer classes, whose 
surroundings are unhygienic and unhealthful, furnish most of the 
cases, and in more than 50 per cent, of all instances of tetany there 
is an associated rachitis which is believed to be an important etio- 
logical factor. 

Beyond this the etiology of tetany is very obscure. It is usually 
preceded by some depressing or debilitating condition, and never 
affects healthy children. Among the different etiologic factors which 
have been mentioned are gastro-intestinal disturbances, infection 
and infestation of the intestines by parasites, the transmissible dis- 
eases, poisoning by alcohol, lead, and ergot, extirpation of the para- 
thyroid glands, or deficient parathyroid metabolism. In some cases 
tetany is supposed to be a manifestation of hysteria. 

Many observers believe tetany to be due to a deficiency of calcium 
salts or a disturbance of calcium metabolism, and artificial tetany 
has been relieved by the injection of calcium. In cases of the disease 
there is a diminution of calcium salts in the brain, an increase of cal- 
cium phosphate and ammonia in the urine, and an increase of ammonia 
in the blood. Tetany is also believed to be of toxic origin. 

Pathology. — Few pathological changes and no characteristic lesions 
have been observed in the small number of cases of tetany which 
have come to autopsy. Dercum mentions as the conditions to be 
found postmortem proliferation of the neuroglia, atrophy in the gan- 
glion cells and nerve fibers, serous exudation into the cervical cord and 
ventricles of the brain, spinal extradural hemorrhage, and sclerotic 
changes in the nervous system. Other observers have reported 
periarteritis, phlebitis, bronchopneumonia, chronic gastro-enteritis, 
tuberculosis of the brain, and hemorrhages into the parathyroid glands. 

Symptoms. — The most important symptoms of tetany are the result 
of mechanical or reflex excitability of the spinal cord and peripheral 
nerves, and they may appear suddenly or gradually. In some cases 
there is a prodromal period, during which the child may be depressed, 
dull, stupid, it may complain of headache or dizziness, and of pain in 
the extremities. This is quickly followed by a tonic spasm of the 
muscles, most marked in the arms, which are held close to the chest, 
and flexed at the elbow, wrist, and finger-joints. The rigidity is some- 



818 



THE NERVOUS SYSTEM 



times so pronounced that it is impossible to overcome the resistance 
of the contracted muscles. 

The muscles of the leg are less commonly affected, and those of 
the face, neck, and trunk are rarely involved. The hand assumes 
a characteristic position, known as the "accoucheur's" or "writer's 
hand," the fingers being flexed on the metacarpophalangeal joints, 
while the phalanges are extended, the thumbs adducted, and the wrist 
is acutely flexed with the hand turned to the ulnar side. The hands 
may also take the position seen in driving. 

The foot may be extended or hyperextended, and the toes flexed. 
Often the feet take the position seen in talipes equinus. In rare 
cases, all of the muscles of the body may be involved (Fig. 119). 




Fig. 89.— Tetany. 



During the periods of latency the contractures lessen, and may 
disappear to such an extent that the only noticeable symptom is 
hyperexcitability of the muscles and nerves. The affection may 
last but a few hours or for several weeks, or the child may have a suc- 
cession of periodic attacks. During the latent periods in which there 
are no active symptoms, certain phenomena may be elicited which 
will enable the practitioner to determine' that he is dealing with 
tetany. 

Trousseau's sign is a spasm of the muscles of the forearm and 
fingers produced when the arm is compressed by an elastic band. 
Chvostek's sign is manifested by a contraction of the muscles of the 
face or forehead when they are tapped; sometimes, as a result of the 
tapping, other muscles of the body also contract. Erb's sign is evoked 
by increased electrical excitability of the peripheral nerves, muscular 



TETANY 849 

contractions being produced by very weak currents. Schultz's sign 
is elicited by stroking the skin over the zygoma, whereupon contrac- 
tures appear, similar to those which constitute Chvostek's sign, but 
Schultz's phenomenon is observed only in the most severe cases, 
therefore is seldom demonstrated. 

Pain is usually present during the spasm, and may be so severe 
as to make the child cry out. Any attempt to overcome the spasm 
greatly increases the pain, and pressure on the contracted part is 
also painful. 

Among the other symptoms of sensory disturbance are tinnitus 
aurium and vertigo. There is no loss of consciousness unless convul- 
sions occur; the urine is rarely affected; the pulse is but slightly 
accelerated; there is no elevation of temperature unless it is caused 
by some associated or underlying condition, or by the toxemia usually 
present. Laryngospasm is a common occurrence. 

Diagnosis. — This offers no difficulty, being based upon the bilateral 
contractions of the hands and feet which are so characteristic of the 
disease, also upon evidences of increased excitability of the peripheral 
nerves, as expressed by the various signs above mentioned. A history 
of preceding gastrointestinal disease, the existence of rickets, and the 
fact that there is no loss of consciousness, are all important points 
which must be taken into consideration. 

Tetanus may be excluded by the location of the contractures, the 
absence of trismus, and the intermittency of the spasms. Meningitis 
may be ruled out by the lack of mental symptoms, while lesions of 
the brain may be dismissed from consideration by the fact that there 
are no local symptoms, and that the contractures in tetany arc bilat- 
eral and symmetrical. Trousseau's sign is demonstrable even during 
the latent periods, and enables one to diagnose the affection when 
spasms do not occur. 

Prognosis. — Tetany is not a fatal disease unless associated with 
general convulsions, although death may ensue as a result of the 
underlying condition; therefore the prognosis depends, to a great 
extent, upon the cause of the affection in each individual case. As 
a rule, cases of tetany due to malnutrition or intestinal toxemia tend 
to recover under proper treatment, while tetany caused by organic 
lesions in other organs or due to eclampsia is more serious, -and the 
outlook not so favorable. 

Treatment. — The treatment of tetany should be directed chiefly 
to the underlying cause which must be eliminated as quickly as 
possible. Rickets, if present, should be promptly treated by regula- 
tion of the diet and the administration of remedies suggested in the 
discussion of the treatment of that disease. Furthermore, since intes- 
tinal toxemia and malnutrition are important factors in the produc- 
tion of tetany in children, any disturbances of the gastro-intestinal 
tract should be corrected, and the diet and nutrition regulated. 

An initial purge of castor oil, 1 to 3 drams, should be given, and 
at intervals of five days or a week these children should take 1 or 2 
54 



850 THE NERVOUS SYSTEM 

grains of calomel in divided doses. An enema of salt solution or soap- 
suds is often productive of good in acute cases. 

These infants should be kept upon breast milk whenever practic- 
able, and artificially fed infants should be given a milk mixture care- 
fully modified to meet the dietetic conditions. 

In addition to this regulation of the diet, the physician should see 
that the child's surroundings are as hygienic as possible, and that it 
gets plenty of fresh air and sunshine. During an attack various 
measures may be employed to relieve the spasm. The child must be 
kept quiet and warm, and all disturbing noises should be prevented. 
A hot bath at 110° F. may be given twice or three times daily for its 
relaxing effect during the attack. In the interval between attacks, 
a salt bath should be given each evening, followed by an inunction 
of olive oil. 

The most valuable sedatives are calcium bromide, sodium bromide, 
and chloral hydrate. Calcium bromide, which may be given in 5- 
to 10-grain doses every four hours, not only counteracts the hyper- 
excitability, but also supplies to the system the calcium which it 
requires. Sodium bromide may be given orally in 1- to 3-grain doses 
every two hours, or may be combined in 5- to 10-grain doses with 
chloral hydrate, grains 1 to 3, and be given by rectum. 

In these cases parathyroid extract usually has no perceptible effect, 
and the administration of calcium lactate, 2 to 5 grains at a dose, 
is followed by no change whatsoever in the condition. 

During convalescence, cod-liver oil, 20 to 60 drops, and iron and 
ammonia citrate, J to 1 grain, or syrupi ferri iodidi, 5 to 10 drops, 
may be given after meals. Outdoor life in the country is a valuable 
aid in promoting speedy recovery. 



CHAPTER XXVI. 
PUBERTY. 

Because puberty lies just on the boundary line between childhood 
and adolescence, this subject is treated fully neither in classical text- 
books on pedriatics nor in treatises on general medicine. This lack of 
comprehensive study probably accounts for the fact that, with many 
physicians, vague notions transmitted by hear-say or empiric writings 
take the place of exact knowledge of the physiological and pathological 
changes which occur at this critical period. 

What is puberty? The name, derived from pubes or pubis (hair), 
would apply physiologically to the time of the appearance of hair on 
the genitals (pubes). This coincides approximately with the estab- 
lishment of the procreative faculty, which is characterized, according 
to sex, by ovulation or the maturing of spermatozoa, and usually, 
but not necessarily, with the growth of pubic hair. Here, however, 
local conditions only are considered, while the profound changes which 
actually occur involve the whole organism, body as well as mind. 

In trying to time this evolution we speak, as always when growth 
and development are concerned, only of the average. It is a well- 
known fact that some girls begin to menstruate at the age of eleven, 
ten, or even less, and others not before their fifteenth or sixteenth 
year, while conception has been reported as early as the eighth year. 
In boys, too, manifestations of puberty are sometimes observed at 
twelve years of age, in others not before, or even later than, eighteen 
years. Equally true is it that while in some children the processes 
of evolution are complete in eighteen months, or even a year, in others 
eight to ten years may elapse before maturity is attained. 

Summarizing, we designate as puberty the whole period of develop- 
ment between twelve and fifteen years in girls and fourteen to eighteen 
years in boys, and this development comprises the series of changes, 
physical and psychical, which transform the juvenile organism into 
the mature one. These great changes, let it be understood, are influ- 
enced by many diverse conditions. They may be premature or 
retarded, rapid or slow, intense or attenuated, according to tem- 
perament, race, climate, nutrition, heredity, sex, and social conditions. 

PERIOD PRECEDING PUBERTY. 

Body. — Following the steadily progressive growth of later child- 
hood up to about the age of ten in girls and twelve in boys, the general 
development of the body seems for a year or two to be reduced to the 
minimum, as if, during this time, Nature were trying to gather strength 



852 PUBERTY 

for the increased rate of growth which is to follow. According to the 
available statistics of different nations, this limitation affects the 
height, weight, and bony system (thorax, skull, pelvis, extremities), 
as well as muscular development. Limitation of growth seems to be 
the general law for this period, and probably holds equally true con- 
cerning the internal organs, although this has not been definitely 
proven except in the case of the liver. 

Toward the close of this phase of life a rapid lengthening, espe- 
cially of the lower extremities, takes place. The growth of the trunk 
is retarded, while that of the thorax is hardly perceptible; therefore 
the respiratory capacity and the size of the heart as compared with 
the height are less than at any later time. As the weight, too, increases 
but slowly, boys and girls of this age are apt to look ungainly, long 
legs, a short trunk, and leanness being their most striking physical 
characteristics. This puerile type, as A. Delpeuch calls it, seems 
essentially to be identical with that of the so-called tuberculous 
diathesis. One cannot but wonder whether those who subsequently 
contract tuberculosis retain their puerile proportions, and are thereby 
predisposed to the disease, or whether the failure to acquire the adult 
conformation is not really the effect of latent tuberculosis. 

Mind. — Emerging from a period of mere imitation, the little boy or 
girl toward puberty begins to exercise the power of reason. The 
knowledge which, before this time, has been merely stored in the 
memory mechanically is now utilized by the mind in forming ideas, 
in comparing, and in generalizing. Reason and judgment, hitherto 
impersonal, become original, more correct, and more definite. The 
attention is more concentrated, reflection is clearer, imagination is 
curbed, and, as the sexual instinct awakens, the affections become 
sweeter and more intense. The feelings, less impulsive, are better 
controlled by a will which now asserts itself. All these different 
mental activities produce a more stabile equilibrium. Discipline is 
more readily borne; behavior, the power of application to work, and 
work itself are improved. The teacher congratulates himself upon 
the changes brought about, and parents see with satisfaction the 
happy modifications in the character of their child. 

PUBERTY. 

Body. — This preparatory period is followed by the most critical 
and interesting phase of life, i. e., puberty. Up to this time the child 
has shown only racial instincts, but he now begins to develop indivi- 
dual characteristics, and family traits become accentuated. A rapid 
development of the organism as a whole sets in, not gradually, but 
by leaps and bounds. Height and weight increase, the muscles 
develop, the general bony system enlarges, and all the viscera seem in 
haste to acquire adult formation. Coincident with this period is the 
sudden development of all the organs of generation, and the forcing 
of their functions, some of which now appear for the first time. 



PUBERTY 853 

There are no fixed rules as to the order in which these changes take 
place; in fact, they appear in almost endless variety, according to 
the influences of climate, race, sex, heredity, and environment. For 
this reason it does not seem quite correct to reckon puberty from the 
development of a single system of the body — for example, the repro- 
ductive. Ovulation or the forming of mature spermatozoa does not 
alone make a mature woman or man, but that combination of physical 
and psychical development which Nature at this time brings about, 
and which is designated as puberty proper. The length of the period 
is variable; but in this country the time between the twelfth and 
fourteenth years in girls can be accepted as the average. Boys pass 
more gradually into adolescence, usually between the ages of fourteen 
and sixteen. 

As to the details of physical development, we find that growth in 
height usually precedes by a few years the pronounced increase in 
weight which takes place during puberty. After a time of slow growth 
during late childhood, girls grow more rapidly from their eleventh or 
twelfth year to their fifteenth year, while increase in weight, marked 
between the thirteenth and fifteenth years, sets in and continues, 
although much more slowly, until the age of twenty. Boys increase 
decidedly in height between fourteen and seventeen, with the maxi- 
mum around the fifteenth year, but no remarkable gain in weight 
occurs, as a rule, until sixteen or seventeen. Speaking generally, we 
may say that until eleven years of age boys, and from then until fifteen 
years of age, girls exceed the other sex in weight and height; after 
fifteen or sixteen years of age girls again fall behind. 

Corresponding with the general growth the shoulders broaden and 
the bony thorax enlarges markedly — as much as five inches in three 
years — making room for the increasing pulmonary development 
which oftentimes raises the maximum capacity by 500 c.c. In girls, 
even in those who wear no corset, it is chiefly the upper thoracic por- 
tion which enlarges, the lower costal region developing much more 
slowly; therefore the girl's breathing tends to the costal type while 
the young man's respiration is usually of the abdominal type. 

The circumference of the head keeps pace with the general develop- 
ment; in girls between the eleventh and thirteenth years it is greater 
than in boys, before and after this age smaller. The bony pelvis widens 
more in girls, its greatest growth taking place between eleven and 
fourteen years, as compared with thirteen to sixteen in boys. Yet 
even at fifteen or sixteen the female pelvis surpasses that of the male 
in size, and is evidently prepared for possible gestation. Muscular 
development, naturally greater in boys, reaches its maximum between 
fourteen and sixteen years in girls and fifteen to eighteen in boys. 
The flesh is firmer and harder in the latter, while in the former it is 
infiltrated with fat, which serves to give to the body a rounded and 
graceful contour. 

Larynx. — In girls the voice rarely breaks, but, on the contrary, 
becomes fuller and more resonant, the larynx enlarging chiefly in its 



854 PUBERTY 

vertical diameter. In boys the transverse diameter increases most, 
the vocal cords are lengthened, and the voice, after a period during 
which it "cracks," is permanently pitched an octave lower than 
before. 

How intimately this and .other developmental changes are related 
to the inner secretion of the organs of generation (testicles) is demon- 
strated by boys emasculated before puberty. Their voices remain 
high, they are slender and narrow chested, their pelves are broad, and 
there is little growth of hair except on the scalp. 

Thyroid Gland. — No less important is the decided influence which 
the thyroid gland exerts upon the growth of the whole bony system, 
and especially on the genital system of both sexes. In about 15 per 
cent, of girls this gland becomes swollen at puberty, and in 60 
per cent, is temporarily enlarged when menstruation appears. 

Hair. — When hair appears on the previously smooth body puberty 
is imminent. In girls a sparse growth begins to show a few months 
before menstruation, first on the pubes, but gradually covering the 
genitalia and axillae. In boys from fourteen to sixteen years of age 
it may also appear over the chest and back, the extensor surfaces 
of the extremities, and upon the upper lip, cheeks, and chin. The 
growth of the beard is, however, not coincident with puberty; in 
fact, in some races this is altogether lacking. 

Circulatory System. — The sudden acceleration of development at 
puberty may cause undue strain on the heart, and, perhaps, a dis- 
proportionate development of body, heart, and bloodvessels. Hence, 
in spite of the fact that cardiac growth is greater during puberty than 
during preceding years, irregular and feeble pulse, palpitation, short- 
ness of breath, and vertigo are frequently complained of, while vaso- 
motor instability is evidenced by blushing, angioneuroses, and func- 
tional albuminuria. 

The Genitalia. — Decided changes now take place in the genital sys- 
tem. The organs become more vascular, rapidly increase in size, 
and mature within two years, whereas three or four years must elapse 
before adolescent weight and height are attained. In girls the labia 
majora hypertrophy and completely cover the vagina; the clitoris 
and the anterior part of the labia minora also increase in size, the 
former becoming erectile, and the vagina turgescent and more 
capacious. 

From a cylindrical shape the uterus changes to the adult form, with 
larger and flattened fundus; its muscular walls and mucous lining 
thicken considerably, and numerous glands develop. 

The ovaries double their weight from J to 1 dram, and twelve 
to fifteen Graafian follicles gradually approach the surface, ready to 
enlarge and burst in turn at Nature's call. More or less coincident 
with these transformations is enlargement of the breasts which causes 
transient pricking sensations, sometimes even painful tension and 
twinging pains along the ribs. 

Abdominal heaviness and a sense of pressure are felt in the pelvis, 



PUBERTY 855 

also tenderness on palpation over the hypogastrium ; occasionally 
there are flashes of heat, congestion of the face, and not infrequently, 
epistaxis, general lassitude, and sacral, iliac, or lumbar pains which 
radiate to the thighs. 

Gastro-intestinal disturbances, such as anorexia, dyspepsia, and 
constipation, as well as nervous palpitations, insomnia, accelerated 
respiration, and increased perspiration, may all be noted. The girl 
is often irritable, extremely emotional, and feels unfit for work. 

In this period between the twelfth and sixteenth years, when the 
whole genital apparatus is turgescent and the vital functions at high 
tide, the first menstruation occurs, lasts sometimes but a few hours, 
usually for a day or two, and ends with the liberation of the first ovum 
and a loss of blood less than that normally lost by the mature woman 
(3 to 6 fluidounces). After a few months the menses become regular 
and the procreative faculty is fully established. 

Genital development takes place a little later in boys than in girls. 
After the first curly hair appears on the external genitalia, the scrotum 
considerably increases in size and in pigment, and its sudorific secre- 
tion becomes more noticeable. Cowper's glands, the prostate, the 
seminal vesicles, and the testicles rapidly approach the adult size. 
At this time nocturnal emissions occur, and may sometimes be pain- 
ful. At first they may contain no spermatozoa; after the fifteenth 
year, spermatozoa are present, and recur at more or less regular 
intervals. 

Boys pass into adolescence more gradually, and always later, than 
girls, other conditions being equal. Many factors influence the begin- 
ning of puberty. With few exceptions, it occurs earlier the higher 
the mean atmospheric temperature. An increase in heat, even when 
it lasts but a short time, causes more rapid growth, and a retardation 
of development has been observed after a fall in temperature. For 
instance, growth during the winter months is only slight, during spring 
and summer it is more rapid, particularly in height, while autumn 
brings a more decided gain in weight. 

A sanguine or nervous temperament, large stature, strong constitu- 
tion, hereditary tendency to precocity, city life, an environment of 
affluence, the use of alcohol, and premature sexual relations — all 
induce early puberty. 

Latin races mature earlier than Anglo-Saxons. Those who grow 
up in poverty lag behind in weight and stature, the period of limited 
growth just before puberty being prolonged and puberty retarded, 
but full development is attained at about the same age as among the 
well-to-do. 

Mind. — At puberty not only the body, but also the mind, passes 
through a crisis, the accompanying psychical phenomena of which 
are, unfortunately, often regarded with indifference or skepticism, 
whereas, in the interests of sound and harmonious development they 
should receive the most careful consideration. The period is character- 
ized by general restlessness and a certain instability of mind, vague 



856 PUBERTY 

aspirations rather than concrete thought dominating the mind. 
There is an ardent desire for knowledge. Rhythm and music, dramatic 
roles and poses, give exquisite pleasure, but the critical faculties 
seem to be more or less dormant. It is the age of ideals, of hopes and 
tender sentiment, of folly and imitation, of self-consciousness and 
over-sensitiveness. There is a proneness to exaggeration. Feelings 
change like the pictures of a kaleidoscope; to use Marfan's apt 
expression, we see a mind in revolt. Girls no longer mix so indis- 
criminately as before, sexual characteristics reveal themselves, and 
inherited traits, good or bad, become more conspicuous. A trait 
wholly absent at this time is not likely afterward to appear. 

The girl's natural grace is enhanced, her love of dress intensified, 
she studies the art of pleasing. At the same time her inborn qualities 
become more pronounced, timidity merges into love of solitude — 
even shyness — natural kind-heartedness becomes unduly tender, 
even eager for unnecessary sacrifice. Early pride turns into haughti- 
ness, indolence into laziness, the innocent ruse of former days buds 
into deception, a good entertainer becomes an incessant chatterbox. 
Highly sensitive, capricious, full of temper, tricks, and pranks, now 
exuberant, now cast down, passing from laughter to tears more quickly 
than sunshine to rain on an April day — such a girl is difficult to manage 
in school or house, and taxes the patience of a saint. Yet, after all, 
her faults are of passive type, as compared with those of boys. 

Just as his physical development is more or less out of proportion 
during the period of his most active growth, so the average adolescent 
boy is, in a psychical sense, an inharmonious personality. He is 
wiser than his teacher, more experienced than his parents — more 
gritty, more witty — in fact, a superior being. He readily becomes 
hypersensitive, argumentative, contrary, overbearing, authoritative, 
contradicting others and himself at every instant. His chief charac- 
teristics seem singularly accentuated, almost to the point of being 
caricatures. He has more than the ordinary self-respect, self-reliance, 
self-consciousness. If naturally benevolent, he makes Utopian plans 
to help the whole world. If a good mixer, he is liable to become an 
inveterate talker, or Munchhausen. His natural cheerfulness borders 
on hilarity, and a lively disposition may become impulsive, violent, 
or even brutal. 

General Health. — The general health at puberty is subject to many 
variations for the simple reason that, in addition to the diseases due 
to ordinary etiological factors, the physiological changes which now 
occur may become pathological if the general development is too sud- 
den, or so disproportionate as to leave certain organs too weak for 
the increased amount of work now demanded of them. While statistics 
show that in middle-grade schools the morbidity among boys is 30 per 
cent., and as high as 50 per cent, in girls, the mortality is compara- 
tively very low. Nevertheless, disturbances (functional as well as 
organic) should receive the closest attention, because neglect at this 
time may be responsible for sequelae that will persist throughout life. 



PUBERTY 857 

Therefore the physiological and psychical development of growing 
boys and girls should be carefully watched that we may guide them 
safely through the Scylla and Charybdis of puberty. Insufficient 
nourishment, uncleanliness, unhygienic surroundings, including bad 
light as well as bad air, a sedentary life, and faulty posture, are no 
doubt now, as at any other period of life, baneful conditions. More- 
over, it is certain that physical overwork which lowers the general resis- 
tance, the overtaxing of the functional activity of immature organs 
(such as the heart, lungs, or kidneys), and mental strain upon the 
nervous system, the heart, respiration, muscular strength, and nutri- 
tion, are in a special sense predisposing, provocative, and aggravating 
etiological factors at puberty. The necessity of protecting young 
boys and girls against them at a time when, stirred by new sensations 
and ambitions, they are apt to go beyond their strength in competi- 
tion with others on the athletic field or in the class-room, cannot be 
sufficiently emphasized. 

Schlossmann and Pfaundler noted that of 600 cases, more or less 
closely connected with puberty, 20 per cent, suffered from disturb- 
ances accompanying menstruation, 15 per cent, from cardiac neuroses, 
10 per cent, from goitre, 15 per cent, from periodical headache, 13 
per cent, from neurasthenia, 13 per cent, from hysteria, 6 per cent, 
from epilepsy, 4 per cent, from chorea, and 5 per cent, from the 
albuminuria of adolescence. 

The mortality from tuberculosis, according to Kirchner, increases 
in boys from 10 to 16, and in girls from IS to 26 deaths to 100 total 
deaths. As disturbances of special organs are treated under their 
respective headings, we shall merely enumerate them rapidly, accord- 
ing to the system principally affected : 

Skeleton. — Faulty position and excessive unilateral exercise, as, 
for instance, in playing the violin or in tennis, may cause curvature 
of the spine, especially when the osseous skeleton is insufficiently 
firm, and the muscles are weak from lack of nutrition and harmonious 
exercise. Genu-valgum may develop from long-continued standing. 
So-called "growing pains" are probably in most cases due to infection, 
overexertion, or slight trauma. Osteitis and periostitis are infrequent. 

Skin and Muscles. — Nevi, previously unnoticed, may enlarge at 
puberty. Eczema, urticaria, seborrhea, and acne seem to be more 
frequent as the general growth becomes more rapid. As regards 
muscles, myositis, torticollis, and the juvenile forms of muscular 
atrophy or dystrophy may occur. 

Circulatory System. — Cardiac disease, especially mitral stenosis, 
often previously unsuspected, manifests itself at puberty, while sys- 
tolic murmurs over the apical and pulmonary areas, palpitation, 
arrhythmia, tachycardia, vertigo, and syncope may appear transi- 
torily, and disappear with progressive development. It is sometimes 
difficult to distinguish these murmurs from permanent changes, 
therefore the prognosis should always be guarded. 

The vasomotor system is ill-balanced; and disproportions between 



§58 PUBERTY 

the heart, bloodvessels, and body may now be observed. Girls are 
especially predisposed to chlorosis; according to some writers this 
deficiency of hemoglobin in the circulating blood is the result of 
Nature's effort to prepare for a possible pregnancy by storing in the 
liver iron from the blood. This form of anemia, as well as others 
following tuberculosis, kidney affections, excessive exercise, and 
repeated severe hemorrhages, or due to undernourishment, should 
receive prompt treatment so that harmonious development be not 
retarded. 

Respiratory System. — A peculiar relationship exists between the 
genital organs and the Schneiderian mucous membrane which finds 
expression in the so-called nasal asthma and coryza of puberty. Con- 
trary to former belief, adenoid growths may persist, and should be 
removed in every case. Attacks of angina, also of tonsillitis with its 
train of symptoms, are common. Spasm of the glottis, aphonia, and 
croupy cough appear in laryngeal affections. If the voice breaks, the 
vocal cords need a period of rest and should not be unnecessarily 
strained by shouting or efforts at loud singing. At puberty the 
asthmatic attacks which accompany bronchitis during childhood 
often absolutely cease. 

Digestive System. — Disturbances of digestion are common at 
puberty, especially when there is a tendency to overeat or to bolt 
the food. Dyspepsia due either to excessive or deficient secretion of 
hydrochloric acid, and even of the atonic or nervous type, is rather 
frequent, particularly in girls. Constipation, colic, and mucomem- 
branous enterocolitis are quite common. If the contents of the bladder 
and rectum are habitually or abnormally long retained (sometimes 
from false modesty), anteflexion or retroversion of the uterus may 
result; while faulty corsets and tight skirt bands are, no doubt, causa- 
tive factors of visceral ptosis, especially when there is a tendency to 
relaxation of the abdominal viscera. 

Diseases of the Urinary Organs. — Diseases of the urinary organs 
are rare. Orthostatic albuminuria usually disappears with adoles- 
cence, enuresis in girls with the establishment of menstruation, and 
in boys when the prostate has attained such size as materially to 
assist in the retention of urine. 

Nervous System. — The nervous system of a healthy young person at 
puberty may present changes which at other times would be con- 
sidered distinctly pathological, and parents and teachers need keen 
insight and great powers of forbearance at this critical period of rapid 
physiological development. Evidences of inherited disease, as, for 
instance, general nervousness, hemicrania, hysteria, latent syphilis, 
and general paresis, or the early mental weakness of dementia precox, 
may be noticed for the first time. Epilepsy rarely decreases, but is 
almost always aggravated to the adult type, or it may now appear. 

Pressure sensations, languor, pain in the back, sleeplessness, and 
the easily induced exhaustion of neurasthenia may often be over- 
looked at a time when neuralgia, cephalalgia, a state of apathy, and 



Puberty 859 

even indolence, are so common. Disturbances of sight manifest 
themselves in many ways, but probably do not depend upon pubescent 
changes. The senses of smell and of taste (pica) are sometimes per- 
verted, and often aural noises are complained of temporarily. 

The phenomena of puberty may come on prematurely as regards the 
body or mind; for instance, menstruation and pregnancy have been 
reported in girls eight and nine years old. In boys sexual and physical 
development are largely coordinate, although in exceptional cases 
repeated seminal emissions have occurred in early childhood. Delayed 
menstruation — that is, true amenorrhea (as differentiated from 
atresia of the uterovaginal canal) — may be caused by congenital heart 
disease or dystrophy of the ovaries and uterus, the latter being usually 
found in conjunction with undeveloped breasts and lack of pubic 
hair. 

A functional form of amenorrhea with anemia, neuroses, and psy- 
choses, is not infrequent after an acute infectious disease, or after 
sudden changes of climate, while vicarious menstruation may occur 
periodically from any mucous membrane. Before, during, and after 
menstruation itself, there are often colicky pains, gastro-intestinal 
disturbances, headache, vertigo, angioneuroses, flashes of heat, and 
urticaria. Leucorrhea, malposition of the uterus, or inflammation of 
its appendages may become manifest or aggravated at puberty. 
Other disturbances, such as dysmenorrhea, metrorrhagia, or inflam- 
mation of the mammary glands, are not uncommon. 

In boys, also, at this phase of life the breasts may become affected , 
and occasionally a sensitive swelling appear in one or both, possibly 
accompanied by pain and redness, which disappear spontaneously 
within a short time. Circumcision may become necessary for phimo- 
sis, which leads to enuresis, masturbation, or balanitis from accumula- 
tion of smegma. Urethritis and orchitis — the latter, as a rule, of 
tuberculous origin — are not rare. Undescended testicles may in time 
from pressure, especially when arrested in the inguinal canal, cause 
painful sensations, and, unless they can be restored to their proper 
place either by operation or a suitable pad, their removal should be 
considered on account of the danger of atrophy or malignant degen- 
eration. 

Glands. — The consequences of absence of testicular secretion, as 
illustrated by young eunuchs; the neuroses and psychoses of ovarian 
dystrophy, acromegaly, gigantism, and infantilism observed in con- 
nection with disturbances of the infundibular gland; the influence 
of the thyroid upon physical and mental characteristics; the exag- 
geration of convulsive phenomena in suprarenal insufficiency — have 
all been so forcibly brought to light in recent investigations that their 
mere enumeration impresses us with the immense importance of the 
internal secretions. The glands producing them seem to be especially 
active at puberty; therefore, a disturbance of their function at or 
before this time must exert a far-reaching influence upon development 
in general. 



860 PUBERTY 

This chapter would be incomplete without mention being made of 
masturbation, a pathological condition doubtless chiefly due to 
inherited' weakness of the will. The inclination for it is marked in 
the mentally deficient, in epileptics, and in idiots. Occasionally 
epidemics of it break out in schools. It is true that with the awaken- 
ing of the sexual impulses, phimosis, vulvitis, eczema, accumulations 
of smegma, vesical calculi, constipation, and similar conditions, by 
irritating the genital nerves, may be the exciting cause. Such local 
conditions should, therefore, in due time receive proper attention. 
Harm does not necessarily follow occasional self-abuse; but, if habit- 
ually indulged in, general nervousness, listlessness, exhaustion, car- 
diac palpitation, migraine, absent-mindedness, loss of memory, dis- 
inclination for work, and anemia may result, and, what seems worse, 
still further weakening of the will. Boys more easily fall victims to 
this habit than girls. Plain, non-stimulating diet, plenty of physical 
exercise, the avoidance of all incentives to sexual passion in literature, 
art, and association, with the correction of the physical factors men- 
tioned, and a plain heart-to-heart talk with a sensible sympathetic 
teacher or parent will be of more benefit than criticism or open rebuke. 



INDEX 



A 



Abdomen, boat-shaped, 822 

concave, 308 

distention of, 297, 556, 621 

dragging sensation in, 494 

fluid in, 357 

neuralgia in, 266 

protuberant, 357 

rigidity of, 337, 353 

tapping of, 356, 384 
Abdominal band, use of, 23, 358 

cavity, testes in, 97 
Abortion due to syphilis, 739 
Abscess, alveolar, 249 

amebic, of liver, 378 

anal, 367 

cold, 518, 524 

ischiorectal, 367 

of appendix, 336, 341 

of brain in mastoiditis, 615 

of joint, 523 

of kidney, 551, 565 

of lymph gland, 498 

of spleen, 494 

pulmonary, 408, 442 

retroesophageal, 262 

retropharyngeal, 609, 658, 726 

subphrenic, 379, 380 

tuberculous, 519 
Absorption of hypertrophy, 310 
Acarus scabiei, 604 
Accommodation, power of, 43 
Acetone bodies, 198 
Acetonuria, 529 
Achondroplasia, cretinistic, 138 

distinguished from cretinism, 513 
from rickets, 238 
Acid fermentation, intestinal, 196 

intoxication, 268 
Acidosis, 199, 205 

acetonemic, 529 

cause of vomiting, 255 
Acids, fatty, in mother's milk, 200 

ingestion of, 276 
Addison's disease, 514 

operation for, 516 
treatment of, 515 
Adenectomy, 399 
, Adenitis, cervical, 496, 650 

simple acute, 495 

from bacteria, 496 
symptoms of, 496 
chronic, 497 



Adenitis, treatment of, 496 

tuberculous, 496, 650, 732 
Adenocarcinomata of liver, 388 
Adenoids, 396, 496, 612 

at puberty, 858 

cause of cough, 438 
of enuresis, 537 
of rhinitis, 393 

effects of, 397 

in chorea, 846 

in idiots, 835 

removal of, 216, 613 

treatment of, 398 
Adenoma, renal, 558 
Adenosarcoma of kidney, 556 
Adiposity in child, 516 
Adolescence, 853 

rickets in, 245 
Adrenal glands, 514 

tuberculosis of, 515 
Adrenalin in hemorrhage, 127, 396 

in pertussis, 695 
Adrenals in Addison's disease, 515 

tumors of, 514 
Agenesis corticalis, 105 
Air, change of, 693 

fresh, for infants, 25 

in treating disease, 212 
Air-borne disease, 639 
Air passages, infection of, 423 

narrowing of, 742 
Albumin in milk, 173, 271 

water, 284 
Albuminuria at birth, 111 • 

cyclic, 527 

functional, 527 

in diphtheria, 660, 66S 

lordotic, 527 

of adolescence, 857 

orthostatic, 527, 858 

paroxysmal, 528 

postural, 527 
Alcohol in bronchopneumonia, 430 

in diarrhea, 286 

in nephritis, 545 

in pneumonia, 421 

a poison to children, 59 
Alcoholic neuritis, 839 
Alcoholism among women, 59 

cause of cirrhosis, 381 
of hare-lip, 82 
of idiocy, 832 
Alexins, 166 
Alimentary intoxication, 207 



862 



INDEX 



Alkalies in acidosis, 529 

ingestion of, 276 

in intestines, 199 
Alkaline diluents, 150 
Allantois, bursting of, 96 
Alopecia areata, 598, 599 

forms of, 598 
Alpine plants, experiments upon, 70 
Altitudes, high, 215 
Alzheimer method, 777 
Amaurotic family idiocy, 832 
Ameba coli in dysentery, 291 
Amenorrhea, true, 859 
Amino-acids, 192 
Amylase, pancreatic and salivary, 

191 
Amyloid disease of intestines, 334 
of kidney, 547, 548 

liver, 384 
Amylopsin, 193 

Amyotrophic lateral sclerosis, 796 
Anaphylaxis, 675, 680 
Anemia, 475 

at puberty, 858 

blood picture in, 476 

cause of heart murmur, 449 

due to worms, 341, 348 

etiology of, 475 

fatal, from jaundice, 374 

from pleural effusion, 433 " 

hemoglobin in, 472 

in familial jaundice, 373 

in rickets, 242 

lymphatic, 484 

pernicious, 478 

primary, 476 

secondary, 475, 482, 484, 491 

simple, 475, 495 

simulated by malaria, 735 

splenic, 483 

syphilitic, 746 

treatment of, 476, 482 
Anencephalia, 80 
Anesthesia for adenectomy, 399 

in thymic disease, 508 

local, 508 
Angina, scarlatinal, 634 
Angioma, 600 

Animal heat of body, 154, 155 
Ankylosis, bony, 522 
Ankylostomum duodenale, 348 
Anthrax differentiated from noma, 

259 
Antibodies in the blood, 120, 167, 612, 

689 
Antiseptics, intestinal, 287 

urinary, 568 
Antitoxin, administration of, 678, 679 

as specific in diphtheria, 679 

diphtheria, 649, 651, 660 
action of, 677 
caution in use of, 680 
early administration of, 672 
production of, 677 

dosage of, 679 

effects of, on mortality, 679 



Antitoxin eruptions, 682 

followed by death, 500 

injection, mode of, 679 

in pseudodiphtheria, 687 

intravenously, 673 

limitations of, 678 

reaction of, 678 

sequelae of, 680 

tetanus, 134 
Anuria, 532 

from atresia of urethra, 104 
Anus, absence of, 94 

artificial, 93 

care of, 26 

diseases of, 361 

eczema of, 366 

fissure of, 365 

fistula in, 367 

imperforate, 326 

inspection of, 363, 365 

itching of, 345 

malformation of, 94 

prolapse of, 362 

stricture of, 329 
Aorta, hyperplasia of, 507 
Aortic disease, 463 

insufficiency, 463 

regurgitation, 459 

stenosis, 454, 459 
Apex beat, 48, 446, 454 
Aphasia, 625 
Aphonia, 837 
Aphthae, Bednar's, 250 
Appendectomy, 340 
Appendicitis, 335 

acute, forms of, 336 

bacteria a cause of, 336 

catarrhal, 337 

chronic, 336, 339 

differentiated from infected 
glands, 727 

diagnosis of, 339 

differentiation of, 339, 623 

gangrenous, 338 

interval operation in, 340 

lesions in, 337 

suppurative, 336, 340 

treatment of, 340 

ulcerative, 336, 338 

vomiting in, 264 
Appendix, anomalies of, 336 

perforation of, 336, 338 

position of, 335 

rupture of, 338 
Appetite, capricious, 333 

in chronic gastritis, 296 

ravenous, 306, 830 
Aprosexia, 398 
Arm, palsy of, 109 
Arnold steam sterilizer, 144 
Arrhythmia, 447, 462 
Arsenical neuritis, 839 
Arteries in diphtheria, 668 

of newborn infant, 19 

vasomotor tone of, 446 
Artery, pulmonary, dilated, 453 



INDEX 



863 



Artery, umbilical, bleeding from, 126 
Arthritis, acute, of infants, 522 

deformans, 759, 781 

from vulvovaginitis, 578 

gonorrheal, 753 

pneumococcal, 753 

rheumatoid, 759 

scarlatinal, 635, 753 

syphilitic, 523, 754, 761 

tuberculous, 524, 753 
Artificial feeding, 178 

indigestion from, 267, 317 

respiration, 114 
Ascaris lumbricoides, 346 
Ascites, 356 

chylous, 356, 357 

fluid in, composition of, 356 

in peritonitis, 355 

treatment of, 358 
Asepsis, effects of, 120 

of cord, 125 
Asphyxia cyanotica, 113 

intra-uterine, 113 

of newborn, 106, 112, 114, 391 

from lesion of nervous system, 
114 

pallida, 113 
Aspiration of cysts, 389 
Aspirin, reaction of, 529 
Assimilation, lost power of, 208 
Asthma, 439 

antitoxin in, 680 

bronchial, 439 

catarrhal, 440 

causes of, 440 

hay, 440 

paroxysms of, 440, 441 

thymic, 500, 506 

treatment of, 442 
Asylum care of infants, 50 
Ataxia, hereditary, 804 
cerebellar, 804 
Atelectasis,- 115 

acquired, 443 

congenital, 443 

diagnosis of, 110 

treatment of, 116 
Athetoid movements, 106, 107 
Atony of intestines, 329 

of stomach wall, 299, 301 
Atresia of bile ducts, 99 

of bowel, 93, 95 

of vagina, 103 
Atrophy, muscular, 795 

of brain, 105 

clinical picture of, 208 

of thymus gland, 35 

yellow, of liver, 376 
Auricular septum, 451 
Auscultation, 48 

in bronchopneumonia, 426 

in children, 456 

in lobar pneumonia, 416 
Autodrainage of brain, 78 
Auto-inoculation, 591, 598, 713 
Auto-intoxication, intestinal, 322 



B 



Babies, handling of, 116 

Babinski reflex, 43, 48, 770, 773, 779, 

782, 797, 806, 816, 822, 825, 827 
Bacilli, growth of, 188 
Bacillus acidophilus, 332 

cause of cholera infantum, 293 

coli, cause of pyelitis, 563 

diphtheria?, 656 

diphtheroid, 485 

dysentery, 279 

gas, 279 

in blood stream, 703 

in stomatitis, 256 

influenza, 423, 701, 705, 813 

Klebs-Loeffler, 392, 677 

lactic acid, 174 

lactis aerogenes, 333 

of Flexner, 279 

of Friedliinder, 423 

of pertussis, 688, 691 

of Shiga, 279, 288 

of Shiga-Kruse, 289 

of tetanus, 133 

pseudodiphthcria, 276 

pyocyaneus, 279 

tuberculosis, 717 

typhosus, 617 

water-borne, 143 
Backwardness, 829, 832 
Bacteria, air-borne, 121 

anaerobic, 442 

cause of appendicitis, 336, 337 
of endocarditis, 457 
of joint disease, 522 

of meningitis, 810 
of osteomyelitis, 517 

cultures of, 670 

in cerebrospinal fluid, 76 

in cow's milk, 141, 142, 143 

in feces, 195 

in healthy membranes, 392, 400 

in kidneys, 541 

in otitis media, 608 

in spinal fluid, 778, 817, 823 

in stomach, 188 

in throat, 686 

in tvmpanic cavity, 608 

intestinal, 332 

lactic acid, 143 

pathogenic, 147 

putrefactive, 143, 146, 196 

pyogenic, 524 

spore-bearing, 144 
Balance, disturbance of, 205 
Balanitis, 572, 582 
Baldness, 233, 599 
Banti's disease, 483. See also Splenic 

Anemia. 
Barium meal, 305 
Barley-water, 149, 239, 284 
Basophiles, 473, 479 
Bath, alkaline, 371 

daily, 320 

hot, in diarrhea, 286 



864 



INDEX 



Bath, hot, in pneumonia, 429 
mustard, 413 

in measles, 652 

in typhoid fever, 626 

infection by, 617 

temperature of, 22 
Bathing of children, 586 

of newborri, 21, 40 
Bednar's aphthae, 250, 257 
Beds, separate, 58*4 
Bed-sores, 291, 713, 814 - 
Bed-wetting, 534, 536 
Beef, inspection of, 343 

juice, 177, 183, 241, 768 
Behring's antitoxin, 677, 679 
Belladonna plaster, 696 
Belt for movable kidney, 563 

for whooping-cough, 695 
Berries, cause of urticaria, 589 
Bezold's mastoiditis, 615 
Bier's hyperemia, 497, 616 

suction apparatus, 118 
Bile, composition of, 369 

ducts, catarrhal inflammation of, 377 
obliteration of, 99, 119, 375 
obstruction of, 369, 376 
stenosis of, 376 

excessive formation of, 118 

free drainage of, 376 

in newborn, 20 

pigment, 100, 370, 374 

salts, 192 
Bilious attacks, 380 
Bilirubin crystals, 119 
Binder, knitted, use of, 23 
Birth injury, 41, 87, 108, 112, 130, 824 

palsies, 106, 108, 792 

premature, 824 

rate and infant mortality, 51 
reduction of, 58 

teeth, 220 

weight, 32, 119 
Bismuth for enterocolitis, 289 

injections, 95 

meal, 95 
Black stools, 273 
Bladder, atony of, 535 

blood-clots in, 568 

calculi in, 537, 569 

control of, 26 

diseases of, 563 

distention of, 533, 569 

exstrophy of, 96 

hemorrhage from, 527 

infection, 564 

inflammation of, 567 

irrigation of, 568 

irritability of, 82, 535, 537 

of newborn, 20 

puncture of, 384 

relief of, 29 

spasm of, 568, 569 
Bleeder's disease, 487 
Bleeding, gastric, fatal, 316 

rectal, 366 
Blindness, 817 



Blood, alteration in, 371 

bodies in, during pregnancy, 117 

casts, 526 

cells, white, in leukemia, 479 

circulation of, 445 
in newborn, 38 

coagulation of, 129, 487 

count in typhoid, 623 

culture in hemophilia, 127 
in sepsis, 123 
in typhoid, 623 

diseases of, 472 . 

dust, 475 

fetal, 38 

human, injection of, 316 

in anemia, 476 

in childhood, 472 

in chlorosis, 477 

in diphtheria, 668 

in infancy, 374, 472 

in leukemia, 480 

in malaria, 733 

in pernicious anemia, 478 

in pneumonia, 418 

in stools, 211, 273 

in syphilis, 744 

in urine, 526 

letting, 114, 611 

leukocytes in, 473 

of newborn, 19 

oozing of, 488 

oxygenation of, 38, 665 

parasite, 732 

physical properties of, 472 

picture in atrophy of liver, 377 

platelets, 475 

reaction of, 472 

red cells in, 472 

serum, human, 127, 314, 489 
in poliomyelitis, 786 

specific gravity of, 472 

supply, maternal, 739 

tubercle bacilli in, 721 

whole, injections of, 128 
Blood-pressure, 445, 447, 470 

after birth, 125 

high, 29 

of nephritis, 542 
Bloodvessels, abnormal, 451 

transposition of, 452, 454 

walls, in scurvy, 765 
Blue babies, 451 
Bodily protective power, 720 
Body fluid in cholera infantum, 293 
reduction of, 326 

hair, excessive, 514 

weight, 33, 445 
Boils, 592 
Bone abscess, 517 

absorption of, 522 

exuberant formation of, 522 

injury, 517 

during labor, 112 

marrow in anemia, 478 
in leukemia, - 480 
red, extract of, 483 



INDEX 



865 



Bones, deformity of, 138 
diseases of, 517 
flat, changes in, 229, 231 
in septic infection, 123 
syphilis of, 519 
tuberculosis of, 518, 520 
Bordet-Gengou bacillus, 688, 691 
Bosses, cranial, 235, 522 

in rickets, 229 
Bothriocephalus latus, 342 
Bottle feeding, 151 
Bottle-fed babies, cholera in, 293 
colic in, 312 
constipation in, 327 
gastritis in, 295 
mastoiditis in, 616 
mortality among, 62, 162 
pertussis in, 691 
pylorospasm in, 301 
rickets in, 241 
scurvy in, 764 
stools of, 273 
summer diarrhea in, 283. 
thrush in, 254 
Bottles, nursing, care of, 183, 223, 283 
Bovine tuberculosis, 718 

vaccine virus, 715 
Bowels, atresia of, 94 
in typhoid, 621 
malposition of, 95 
obstruction of, 323, 360 
regular habits of, 93 
twisting of, 335 
ulceration of, 292 
Bow-legs, 24, 237, 244 
Boys, breasts of, 859 

development of, 853, 855 
masturbation in, 860 
puberty in, 851 
vocal cords of, 854 
Brachial plexus, plan of, 110 
Bradycardia, 447 
Bradylalia, 827 
Brain, abscess of, 610, 615 
absence of, 80, 81 
autodrainage of, 78 
capacity, 71 

cells, transmission of, 70 
congenital maldevelopment of, 75 
demand for blood in, 819 
diseases of, 824 
development of, arrested, 105 

in infant, 28 
hernia? of, 72 
malformations of, 72 
miliary tubercles in, 728 
syphilitic changes in, 743 
tuberculosis of, 721 
tumors, 80, 813 
weight of, 42, 769 
Branchial clefts, 86 
Bread, secretion produced by, 187 
Breast feeding, 158 

advantages of, 161 
frequency of, 160 
impossibility of, 161 
55 



Breast feeding in pylorospasm, 303 
regularity in, 160 
supplemented by bottle, 162 
milk, amount of, 164 
analysis of, 163 
average composition of, 165 
cause of indigestion, 163 
diminution of, 162 
effect of alcohol upon, 59 
fat content of, 268 
retention of, 117, 164 
standard, 162 
Breast-fed babies, mortality among, 62 
Breasts at puberty, 859 

bacterial infection of, 118 
caked, 283 
enlargement of, 854 
inflammation of, 161 
of infants, milk in, 117, 118 
Breath, foul, 250, 660 

in pyorrhea, 260 
gangrenous, 443 
pear-like odor of, 265 
urinous, 543 
Breathing, bronchial, 416, 420, 435 
Cheyne-Stokes, 822 
exercises, 438, 442 
impaired, 397 
in sexes, 853 
Breathlessness, 457 
Breck feeder, 83 
Breech presentations, birth injuries in, 

108, 112 
Bromide rash, 605 
Bronchi, diseases of, 408 
Bronchial glands, suppuration of, 726 

tubes, narrowing of, 440 
Bronchitis, acute, 408 

auscultation in, 410 
etiology of, 409 
expectoration in, 410 
mild form of, 410 
pathology of, 409 
percussion in, 410 
prophylaxis in, 411 
respiration in, 411 
severe type of, 411 
symptoms of, 410 
treatment of, 412, 413 
asthmatic, 440, 441 
differentiated from pneumonia, 419 
in pertussis, 689 
in rickets, 232 
Bronchophony, 416 
Bronchopneumonia, 423 

accompanying enterocolitis, 288 

as a house disease, 423 

bilateral, 424 

complications of, 427 

convalescence in, 430 

cyanosis in, 430 

diagnosis of, 426 

differentiation of, 424 

due to diphtheria bacillus, 679 

in diphtheria, 666 

in dysentery, 290 



866 



INDEX 



Bronchopneumonia in infants, 423, 427 

in measles, 644, 649 

in pertussis, 691 

masking whooping-cough, 427 

mortality from, 63 

prophylaxis of, 427 

relapse in, 425 

sick-room in, 428 

stimulation in, 430 

symptoms of, 424 

treatment of , 428 

tuberculous, 722, 724 
Bronchus, foreign body in, 443 

occlusion of, 416 
Broths in diet, 289 

meat, for infants, 177 
Brown-Sequard syndrome, 780, 806 
Bruidzinski's sign, 774, 816, 821 
Bruit, 447. See also Murmurs. 

aortic, 458 

de galop, 635 

in mitral stenosis, 463 

right-sided, 450 
Brunner's glands, 19, 191, 192 
Buhl's disease, 121, 128, 130 
Bulbar palsy, 789 
Bulgarian bacillus, 175 
Burial clubs, 58 
Buttermilk, 174, 175, 320 
Buttock, eczema of, 200, 281, 318 

pus in, 368 



Cachexia, fatty liver in, 385 

in kidney tumor, 556 

in lymphatic anemia, 485 
Calcification in rickets, 231 
Calcium phosphate, 158 

salts, 189, 229 
Calculi, urethra], 532, 569 

vesical, 567 
Calmette test, 731 
Calomel fumigation, 686 

in acetonuria, 529 

in gastric indigestion, 275 

purgation, 329, 372, 677 
Caloric feeding, 179 
Calorie production in infancy, 40 
Calories, infant requirement of, 160 

in food elements, 155 
Camp life, 215 

Canal of Nuck, hydrocele of, 98 
Cancrum oris, 257 
Cane sugar, 269, 270 

alcoholic fermentation in, 179 
Caput succedaneum, 78 
Carbohydrate indigestion, 157, 269, 319 
Carbohydrates, cause of fat, 386 

excessive use of, 317, 530 

in flours, 157 

in infant's food, 200 

in mother's milk, 156 

value of, 196 

variety of, 178 
Carbolic acid, use of, 592 



Carbon dioxide in blood of newborn, 116 
Cardia, ulceration of, 315 
Cardiac depression, 653 

dulness, areas of, 49, 455, 466 
increase in, 464 
Cardiorespiratory centre, 772 
Cardiospasm, congenital, 88 
Carditis, 469 
Caries, dental, 222, 225, 250 

vertebral, 781 
Carotids, throbbing of, 463 
Carpopedal spasm, 404 
Carriers of disease, 121, 629, 658, 663, 

793, 815, 818 
Cartilage, production of, 229 

ossification of, 138 
Cascara sagrada, 329, 333 
Caseation, tuberculous, 497 
Casein, cause of indigestion, 272 

clotting of, 154 

curds, 145, 201 

in stools, 211, 272 

of milk, 154, 189 

precipitation of, 189 
Castile soap, cones of, 328 
Castor oil in dysentery, 291 

purgation, 253, 255, 271 
Castration, 574 

effect of, on thymus, 502 
Casts, hyalin, 385 

membranous, 660, 665 

of larynx and trachea, 687 

urinary, 669 
Catarrh of air passages, 411, 428 

postnasal, 438 
Catarrhal affections, 818 

fever, 701. See also Influenza. 
Cathartics, hydragogue, 358 

saline, 330 
Cathelin's treatment, 538 
Catheter, feeding by, 248 

for infant enema, 148 

passage of, 533, 569, 579 
Cattle, tuberculosis in, 718 
Cauda equina, tumor in, 807 
Cauterization, 90, 581, 612 
Cautery, actual, in noma, 259 

in myelitis, 784 
Cavities, dental, 225 

of heart, abnormal, 452 
Cavity in spinal cord, 803 

tuberculous, 442, 722 
Cecum, worms in, 344, 345, 348 
Cellulitis, 496 

Cellulose, utilization of, 157 
Cephalhematoma, 78, 80 

double, 79 

symptoms of, 80 

treatment of, 80 
Cephalocele, 72 
Cereal diluents, 149 
Cereals in diet, 183, 201, 328 
Cerebellum, development of, 43 
Cerebral irritation, 638 

puncture, 778 

softening, 501 



INDEX 



867 



Cerebral tumor, symptoms of, 516 
Cerebrospinal fluid, contents of, 76 

examination of, 809, 811, 812, 

823 
findings in, 817 
meningitis, 814 
acute, 817 

forms of, aberrant, 816, 817 
malignant, 816, 817 
postbasic, 816, 817 
joints in, 754 

symptoms of, nervous, 816 
Cereo gruel flour, 156 
Cervical adenitis, 496 

tuberculous, 718, 727 
glands, enlarged, 495 

inflammation of, 495 
removal of, 487 
Cesarean .section, 79, 140 
Cestodes, 341 

Chamber, child's use of, 330 
Chancre, 738, 739 
Characters, acquired, 69 -. 
individual, 852 
inherited, 71 
transmission of, 68, 69 
Charcot-Leyden crystals, 441 
Chest, capacity of, 853 

deformity of, 233, 235, 398 
systolic retraction of, 468, 469 
wall, incision of, 380 
Cheyne-Stokes breathing, 783 
Chicken-breast, 235 
Chicken-pox, 639. See also Varicella. 
Child-crowing, 404, 406 
Child labor, 29, 34 
Chilling of body, 137, 313 
Chloride retention, 545 
Chloroform in reducing prolapse, 364 
Chlorosis, 476 

blood picture in, 477 
etiology of, 477 
from auto-intoxication, 477 
symptoms of, 477 
treatment of, 482 
Cholelithiasis, 378 
Cholera, Asiatic, 294 
infantum, 292 
bacilli in, 293 

degenerative changes in, 293 
diagnosis of, 294 
etiology of, 292 
pathology of, 293 
stimulation in, 295 
stools in, 293 
symptoms of, 293 
Cholagogues, 279 

Chondrodystrophy, 138. See also Achon- 
droplasia. 
Chorea, 841 

at puberty, 857 
cause of pericarditis, 465 
diet in, 845, 846 
electric, 841 
epidemic, 844 
forms of, 841 



Chorea, imitation in, s41 

in rheumatism, 747, 752 

mental state in, 844 

minor, 841 

movements in, 772, 843 

relapses in, 844, 846 

rheumatic, 846 

sex in, 842 

simulated by exophthalmos, 509 

symptoms of, 842 

treatment of, 845 
I Choroid, tubercles in, 725 
Choroiditis, both eyes, 697 
Chvostek's sign, 774, 848 
Chyme, composition of, 193 
Circulation, fetal, 18, 37, 445 

hemoglobin in, 527 

in bronchopneumonia, 425 

postnatal, 18 

pulmonary, establishment of, 125 

unstable, 507 
Circulatory system at puberty, 854, 857 
Circumcision at puberty, 859 

diphtheritic infection in, 667 

dysuria following, 532 

for balanitis, 572 

for phimosis, 571 
Cirrhosis, atrophic, 381 

cardiotubercular, 381 

hypertrophic, 382 

of liver, 381, 383 

syphilitic, 383 
City life in relation to infant mortality, 
53 

summer diarrhea in, 331 
Cleanliness of mouth, 251 
Cleft palate, 82, 84, 85 
Clefts, branchial, 68 
Climate, change of, in influenza, 707 
in tuberculosis, 731 
' in asthma, 442 

in nephritis, 546, 550 
Clonus, ankle, 773 

patellar, 773 
Clot, cerebral, operation for, 108 
Clothing of infant, 22, 23 
Club-fingers, 449 
Club-foot, 798 

in myelocytocele, 101 
Coagulose, 314 
Cod-liver oil in rickets. 241, 242 

in tuberculosis, 732 
Coffee bv rectum, 278 
Cold air treatment, 214, 216 

applications, in prolapse, 364 
to heart, 509 

cause of nephritis, 542 
in head, 391 
severe, exposure to, 818 
Colic, 312 

differentiation of, 313, 339 
from indigestion, 200, 270, 319 
gall-stone, 311 
habitual, 272, 314 
renal, 556 
symptoms of, 204 



868 



INDEX 



Colitis, amebic, 291 

catarrhal, 766 

mucous, 333 

ulcerative, 362 
Colle's law, 740 
Colon, absorption in, 194 

bacillus in urine, 537 

dilatation of, congenital, 92, 93 

distention of, 300 

flushing of, 533, 546, 845 

irrigation of, 286, 291 

location of, 557 

worms in, 345, 348 
Color index in newborn, 19 
Colostrum corpuscles, 31, 159, 161 
Compensation in children, 464 

ruptured, 460, 462 

secondary, 504 
Complement-fixation test, 691 
Conception at early age, 851 
Concretions, fecal, 336 
Condensed milk, 150, 317 

in scurvy, 764 
Congestion, pulmonary, 321, 429 

renal, 539 

venous, 137 
Conjunctiva, icterus of, 120 

pearly, 475 
Conjunctivitis, 224 

in measles, 647 

in varioloid, 711 
Consanguinity, 68, 510, 829 
Constipation, cause of hemorrhoids, 365 
of vomiting, 265 

chronic, 326 

due to atresia, 94 
to diet, 202, 327 
to dilatation of colon, 92 

etiology of, 326 

from fat indigestion, 200 

from intoxication, 282 

hereditary, 326 

in intussusception, 324 

symptoms of, 326 

treatment of, 329 
Contractures, 790 

in muscular paralysis, 800 
Convulsions, causes of, 772 

control of, 106 

due to rickets, 233 

from atresia of bile ducts, 101 

in catarrhal gastritis, 276, 278 

in cerebral palsy, 827 

in diphtheria, 659 

in idiocy, 830 

in laryngeal spasm, 404 

in measles, 650 

in natal paralysis, 107 

in pneumonia, 420, 422 

infantile, 698 

treatment of, 243 

uremic, 105, 546, 637 
Cord, encysted hydrocele of, 98 

spinal, malformations of, 72, 778 

umbilical, asepsis of, 121 
bleeding from, 126 



Cord, umbilical, desiccation of, 124 

hernia of, 90 
Corpus callosum, puncture of, 78 
Coryza acquired by contact, 427 

diphtheritic, 392 
Cough, expiratory, 689 
in asthma, 441 
in bronchopneumonia, 425 
in chronic gastritis, 296 
in measles, 646, 652 
in mitral disease, 438 
in pertussis, 689, 690 
" nervous, 439 
paroxysmal, 406 
persistent unproductive, 261 
reflex, 438 
Coullet dining-rooms, 57 
Councilman's protozoon, 708 
Counter-irritation, 412, 429, 539 
Country air, 215 

Cow-pox, 713. See also Vaccinia. . 
Cow's milk as infant food, 152 
bacteria in, 141 
care of, 141 
coagula of, 45 
compared with, breast milk, 

167, 168 
composition of, 141 
diluents of, 149 
milk sugar in, 156, 168 
modification of, 167, 303 
production of, 141 
protein in, 154 
raw, 146 
Coxa vara, 237, 238 
Craniotabes, 521, 522 
as a symptom, 48 
in rickets, 234, 237 
Cranial puncture, 778, 810 
Cranium, fluid within, 75 

thin spots in, 521 
Cream, bacteria in, 142 

fat content of, 169, 172, 181 
gravity, 169 
in milk, 173 

mixtures, 168, 172 
intolerance to, 304 
whey mixtures, 271 
Creeping, 42, 244 
Crib for infant, 24 

tent, 686 
Creosote for bronchitis, 412 
Crepitation, 416 
Cretinism, 510, 829 
diagnosis of, 512 
differentiated from rickets, 238 
endemic, 510 
hereditary, 510 
pathology of, 510 
prognosis of, 513 
simulated, 349, 835 
symptoms of, 510 
treatment of, 513 
Cretins, appearance of, 510 
mentality of, 511 
training of, 511 



INDEX 



869 



Crises, abdominal, 492, 515 
Croup, catarrhal, 671 

false, 400 

membranous, 665, 671 

spasmodic, 400 

tent, 412, 429 
Crowing, laryngeal, 404, 406 
Cry, hydrocephalic, 821 

of child, significance of, 49 
Cryptorchidism, 97 
Crystals, calcium oxalate, 528 

uric acid, 528, 554 
Culture tubes, 670 
Cultures, diphtheria, 657, 663, 671, 673 

from urine, 531 

negative, 674, 687 
Cupping, dry, 413, 421 
Curdling in stomach, 188 

of milk, 189 
Curds, casein, 201 

in stools, 194 

of protein indigestion, 201 
Curette, use of, 399 
Curschmann's spirals, 441 
Cyanosis as a symptom, 47 

in bronchopneumonia, 424 

in pulmonary stenosis, 454 

in newborn, 451 

of atelectasis, 115 

of lips, fingers, and toes, 462 

treatment of, 471 
Cyclic vomiting, 264 
Cyst, abdominal, 357 

congenital, 105 

echinococcic, 369 

hydatid, 389 

of kidney, 558 

of liver, 389 

of neck, 87 

of umbilicus, 89 

parasitic, 495 

retention, 389, 558 

rupture of, 389 

tapeworm, 342 

unilocular, 389 
Cystic duct. See Bile Ducts. 

kidney, congenital, 560 
Cystitis, 567 

after typhoid, 567 

chronic, 567 

etiology of, 567 

in influenza, 705 

treatment of, 567 

with pyelitis, 565 
Cytology of spinal fluid, 817 



Dactylitis, syphilitic, 236, 520, 744 

tuberculous, 520 
Dairy farms, model, 142, 144 
Dampness, 748, 759 
Deaf-mutism, 68, 86, 635 
Deafness, causes of, 68, 817 

in cretins, 511 



Deafness in diphtheria, 666 

in idiocy, 831 

syphilitic, 743, 745 
Decomposition, alimentarv, 207 
Defecation, 330 

habits of, 530 

painful, 307 
Defects, physical, 830 
Deformity, ataxic, 805 

bony, 229, 519 

from cicatrix, 742 

in rickets, 240, 244 

of chest, causes of, 37 

of neck, 87 
Degeneracy in type, 71 
Degenerates, moral, 832 
Degeneration, reaction of, 774 
Delirium in cholera infantum, 294 

in diphtheria, 667 

in meningitis, 610 
Dental sacs, 217, 219 
Dentin, formation of, 219 
Dentition, 217, 219 

a natural process, 50, 218 

cause of disease, 217 

conditions due to, 223 

complete, diet after, 183 

delayed, 221, 835 

fever, 432 

in rickets, 221, 233 

multiple, 222 

normal, 185 

premature, 220 
Dermatitis exfoliativa neonatorum, 602 

gangrenous, 601 

medicamentosa, 605 
Desquamation in scarlet fever, 633 
Development affected by temperature, 
855 

before puberty, 851 

cerebral, arrested, 832 

defective, 450, 557, 562, 829 

mental, 829, 852 

muscular, 853 

of body, 830, 851 

of child, 28 

of fetus, 450 

of man, 68 

of senses, 771 

physiological, 770 

precocious, of genitalia, 581 

psychological, 771 
Dextrin-maltose, 179, 270, 271 
Dextrocardia, 454 
Diabetes, cause of enuresis, 536 

insipidus, 534 

mellitus, 390, 530, 534 
Diabetics, acetonuria in, 529 
Diapers, 23, 27, 284 

disease transmitted by, 577 
Diaphragm, tugging of, 672 
Diarrhea, 331 

causes of, 331 

classification of, 332 

during teething, 224 

epidemic, 53, 60 



870 



INDEX 



Diarrhea, fatty, 197 

in measles, 651 

infantile, 60, 698 

infectious, 279 

mortality from, 56, 61, 698 

summer, 279, 280 

treatment of, 332 
Diastase in infant feeding, 149 
Diathesis, lymphatic, 495 

rheumatic, 747, 752 

tuberculous, 852 
Diazo-reaction, Ehrlich's, 623 
Diet after weaning, 183 

at given ages, 183 

in bronchitis, 412 

in cirrhosis, 383 

in diarrhea, 332 

in endocarditis, 461 

in gastritis, 278 

in ileocolitis, 322 

in mucous colitis, 334 

in myocarditis, 471 

in nephritis, 545 

in pneumonia, 420 

in pylorospasm, 303 

in rickets, 241 

lack of residue in, 327 

necessity of fat in, 199 
proteins in, 202 

semisolid, 278 

soft, 625 

vegetable, 191 
Digestion, effect of, on spleen, 493 

in hot weather, 279 

in newborn, 19 

normal, 184 
Digestive apparatus, functions of, 186 

system, strain upon, 246 
Dilatation of colon, 92, 93 

of stomach, 299 
Diluents, 149, 150 
Diphtheria, 656 

after measles, 649 

antisepsis in, 675 

antitoxin, .128, 402, 541, 638, 651, 
665, 672 
administration of, 681 
death following, 680 
dose of, 678, 681 
in nephritis, 545 
in pneumonia, 679 
production of, 677 
repeated injections of, 681 
value of, 679 

bacillus, 657 

in nose, 662, 663 
virulence of, 658, 661 

bacteriology in, 670 

carriers, 658, 663 

cause of neuritis, 836 

complications of, 541, 668 

conjunctival, 667 

contagion of, 656 

cultures, 657, 666, 670 
negative, 663 

diagnosis of, 670 



Diphtheria, diet in, 676 
differentiation of, 671 
discharge in, 392 

nasal, 660, 676, 678 
disinfection in, 673 
epidemic, 672 
etiology of, 656 
false, 686 

feeding in, after intubation, 683 
fever in, 667 

followed by myocarditis, 470 
gastro-enteritis in, 670 
hemorrhage in, nasal, 670 
immunity to, 674, 677 
in hospitals, regulations concerning, 

664 
incubation period in, 658 
irrigations in, 664 
isolation in, 661 
kidneys in, 668 
laryngeal, 665, 685 

suffocation in, 666 
laryngotracheal, 669 
leukocytosis in, 474 
lungs in, 669 
membrane formation in, 660, 662, 

672, 685 
morbid anatomy of, 668 
mortality from, 672, 698 

effects of antitoxin on, 679 
nasal, 660 

antitoxin in, 665 

irrigation in, 664 
nasopharyngeal, 673 
nervous disturbances in, 667 
odor in, 659 
operation in, 682 
paralysis in, 669, 678 
pharyngeal, 658 
prognosis in, 672 
prophylaxis in, 673 
pulse rate in, 667 
relapses in, 680 
reporting of, 661 
return cases of, 663 
scarlatinal, 686 
septic, 667 
sequelae of, 668 
severe types of, 660, 672, 678 
simulated by pseudodiphtheria, 686 
spread by milk, 143 
stimulation in, 677 
stools in, 660 
streptococcus, 686 
sudden death in, 669 
susceptibility to, 658 
swallowing in, 684 
symptoms of, 659 
throat in, 675 
thymic death in, 507 
transmission of, 658 
treatment of, after intubation, 683 

by drugs, 676 

by irrigations, 664, 676 

by serum. 677 

constitutional, 676 



INDEX 



871 



Diphtheria, treatment of, hygienic, 675 
in Widener School, 681 
local, 675 

urine in, 660 
Diphtheritic paralysis, 836 
Diplegia, cerebral,' 825, 826 
Diplococcus found in chorea, 842 

Gram-negative, 815 

intracellularis meningitidis, 814 

of Frankel, 702 

pneumoniae, 414 
Dirt-eaters, 349 

Disfigurement from smallpox, 712 
Disinfection after measles, 652 

in diphtheria, 673, 675 

in scarlet fever, 636 

in typhoid, 625 

in varioloid, 712 

of nasal passages, 393 
Diuretics, alkaline, 529 

for ascites, 383 
Diverticulum, Meckel's, etiology of, 89 
Dog bite, 502 
Douche, cold water, 364 

vaginal, 579 
Drainage of brain, 78 
Drooling, 185, 223 
Dropsy in anemia, 478 

in nephritis, 550 
Drowsiness in meningitis, 821 
Drug rashes, 634 
Drugs, cause of purpura, 489 
Dubini's disease, 841 
Ductus arteriosus, 19, 38 
patent, 450, 453 

omphalomesentericus, 88 
Dulness, splenic, 493 
Duodenum, inflammation of, 279 
Dwarfs, 138, 512, 745 
Dwelling, maximum temperature in, 41 

size of, 215 
Dysarthria, 827 
Dysentery, 289 

amebic, 289, 291 

bacillary, 289, 291 

cause of prolapse, 363 

complications of, 291 

diet in, 292 

hygiene of, 292 

opium in, 292 

resembling enterocolitis, 287 

treatment of, 291 

ulcerative, 290 
Dyspepsia, 206 

at puberty, 858 

in heart disease, 462 
Dyspnea after intubation, 683, 684 

due to thymus, 505 

in bronchopneumonia, 425 

in diphtheria, 665 

laryngeal, 401, 406 

relief of, 444 
Dystrophy, muscular, 798 

facies-scapulohumeral, 798, 801 
pseudohypertrophic, 798 
scapulohumeral, 798, 801 



Dysuria, 532 

from calculi, 532 
treatment of, 532 



Ear, bone necrosis in, 613 

diseases of, 607 

discharge from, 611, 613 

drum, perforation of, 609, 613 

puncture of, 611, 614, 653, 696 

examination of, 611, 613 

foreign bodies in, 607 

furuncles in, 610 

inflammatioD of, 225 

middle, disease of, 398 

noises in, 609, 610 

pus in, 609 

syringing of, 607, 612 

ulceration in, 613 
Eating between meals, 320 

hurried, 274 
Eberth's bacillus, 617 
Ecchymoses in atrophy of liver, 378 

in purpura, 491 

in scurvy, 766 
Eclampsia, 503, 813 

after serum therapy, 503 

infantile, 225 
Eczema, etiology of, 586 

facial, 204 

from pediculi, 603 

moist, 594 

of anus, 321 

of genitalia, 571 

of lips, 247 

of scalp, 587 

pustular, 587 

subacute, 588 

treatment of, 587 

vesicular, 586 
Edebohls' operation, 551 
Edema due to anemia, 475 

to potassium iodide, 402 

in heart disease, 466 

in nephritis, 543 

inflammatory, 403 

of legs, 382 

pulmonary, 507 
Effusion, abdominal, 469 

pericardial, 467 

pleural, 431, 469, 727 
Eiweissmilch, 173, 271, 284, 320 
Electrical reactions, 840 

stimulation in infancy, 41 
Electricity for constipation, 329 

in infantile paralysis, 794 

in myotonia congenita, 802 

in removal of moles, 601 
Emasculation, 854 
Embryo, effects of poisons on, 450 
Embryonal tissue a site of tumor, 556 
Emetics, 685 
Emphysema, 444 

compensatory, 444 



872 



INDEX 



Emphysema due to asthma, 442 
to foreign body, 408 

interstitial, 444 

subcutaneous, 444 
Empyema, 430. See also Pleurisy. 

bilateral, 438 

leukocytosis in, 474 

operation for, 436 

prognosis of, 436 

sacculated, 435 
Enamel, formation of, 221 
Enanthem of rubella, 655 
Encephalitis a cause of palsy, 825 
Encephalocele, 74 
Encephalomyelitis, 779 
Encephalopoliomyelitis, 828 
Endocarditis, 650 

acute, 457 

diagnosis in, 460 
treatment of, 460, 461 

chronic, 461 

physical signs of, 462 
prophylaxis of, 464 
pulse in, 462 
symptoms of, 462 
treatment of, 464 

fetal, 450 

from bacteria, 457 

in rheumatism, 750 

malignant, 457, 459 

postnatal, 457 

rheumatic, 756 

ulcerative, 460 
Enema for colic, 313 

soap, 328 
Enemata, abuse of, 328 

nutrient, 148, 266 
Engorgement, venous, 433 
Enteralgia, 312 
Enteritis in bottle-fed babies, 62 

infantile mortality from, 56, 61 

tuberculous, 530 
Enterocolitis, acute, 287 
etiology of, 287 
treatment of, 289 
Enuresis, 534 

after puberty, 536, 858 

and fecal incontinence, 330 

causes of, 537 

diurnal, 534 

due to diabetes, 536 

to malformations, 535 

from vulvovaginitis, 578 

inherited tendency to, 535 

treatment of, 538 
Environment as factor in infant mor- 
tality, 54 

change of, 320 

effects of, 69, 70 
Enzymes from intestinal wall, 192 

proteolytic, 188 
Eosinophilia, 341 

due to worms, 341, 343, 347 
Eosinophiles, 473, 474, 479 
Epidemic dysentery, 291 

meningitis, 814 



Epidemic pemphigus neonatorum, 601 
Epidemics in institutions, 128 

of diphtheria, 661, 672 

of measles, 642, 643, 644 

of pertussis, 695 

of scarlet fever, 628 

of summer diarrhea, 280 

of tetany, 847 

of typhoid, 624 
Epidermis, maceration of, 590 
Epididymis, inflammation of, 573 

tuberculous, 574 
Epididymitis in mumps, 700 
Epilepsy at puberty, 857, 858 

in cerebral palsy, 826 

Jacksonian, 816, 822 
Epileptics, urine of, 529 
Epinephritis, 551 
Epiphysis, infection in, 518 
Epiphysitis, acute, 522 

syphilitic, 519, 746 

tuberculous, 523 
Epispadias, 96, 104 
Epistaxis, 395 

in cirrhosis, 382 

in rheumatism, 754 

renal, 526 
Epithelium, desquamation of, 288, 290 
Equilibrium of body, 799 
Equinovarus, 798 
Erections in children, 583 
Erb's myotome reaction, 803 

palsy, 108, 109, 110 

phenomenon, 774, 848 
Eruption, bullous, 601 

due to drugs, 605 

exudative, 595 

papular, 593, 594 

papulopustular, 606 

pustular, 593, 709, 740 

scaly, 587, 594 

"shot-like," 711 

syphilitic, 743 

urticarial, 713 

vesicular, 591, 593, 601, 639 
Erysipelas differentiated from eczema, 
587 

of ear, 615 

of newborn, 131 
Erythema multiforme, 593 
Erythrocytes in the blood, 472 

maternal, 118 
Esophagitis, 261 

from acids or corrosives, 262 
Esophagus, congenita] malformation of, 
88 

foreign body in, 261 

rupture of abscess into, 262 

stricture of, 262 
Ether in reduction of hernia, 361 
Eunuchs, 859 
Euquinine, 737 
Eustachian tube, blocking of, 608 

infection in, 614 
Evolution in higher animals, 70 

processes of, 851 



INDEX 



873 



Examination, bacteriological, 670 

clinical, 46 

electrical, 774 

medical, of children, 28 

microscopic, 497, 576 

of ear, 609, 614 

physical, of heart, 454 

sensory, 774 
Exercise for infant, 24 

in heart disease, 465 

unilateral, 857 
Exhaustion products, 450 
Exophthalmic goitre, 509 
Expression, pinched, 456 
Extremities, atrophy of, 796 

blue, 296 

deformity of, 236, 244 

edema of, 321 

lengthening of, 852 

lower, paralysis of, 669 
' spasms of, 846 

weakness of, 831 
Exstrophy of bladder, 96, 97 
with epispadias, 104 
Extubation, 684 
Exudate in meningitis, 820 
Eye reaction, 731 

strain, 846 

symptoms in palsy, 111 
Eyelid, descent of, 509 
Eyes, bulging, 509 

care of, 26 

in measles, 644, 650 

infection of, 580 

inflammation of, 817 

puffiness of, 384 



Face of newborn infant, 17 

pasty, 543 
Facial expression, 456, 835 

palsy, 111, 837, 839 
Factory women, infants of, 52, 56 
Fainting attacks, 456 
Familial jaundice, 373, 374 
Family disease, 795, 798, 802, 804 

history, 46 

traits, 852, 856 

transmission of disease, 487 
Faradic current, 329 
Faradism in Erb's palsy, 110 
Fat absorption, 502 

assimilation of, 292 

cream, percentages of, 180 

deposition of, 155 

diarrhea, 200 

droplets in liver, 377, 386 

in infant's food, 177 

in stools, 195, 211 

indigestion, 151, 199, 267 
in bottle-fed babies, 267 
stools in, 274 

injuries, 200 

intolerance to, 268 



Fat metabolism, 155 

mixtures for constipation, 328 

of cow's milk, 205 

percentages, 171 

taking on of, 514 
Fats, 155 

digestion of, 193 

splitting of, 191 

variety of, 178 
Fatty degeneration of newborn, 128 

liver, 385 
Faucitis, diphtheroid, 671 
Fecal matter, absorption of, 322 
Feces, color of, 210 

composition of, 195, 211 

consistency of, 211 

discharge of, at umbilicus, 89 

examination of, 209 

form of, 195 

incontinence of, 330, 333 

normal, 194, 273 

of newborn, 273 

reaction of, 209 
Feeble-mindedness, 828 
Feeding after intubation, 683 

after weaning, 183, 317 

artificial, 206 

by catheter. 21s 

excessive, 205 

improper, cause of indigestion, 274 

of infants, 141 

percentage, 172 

problem, 203 

regularity in, 317 
Feedings, infrequent, in summer, 283 
Ferment, fat-splitting. 45 
Fermentation, gastro-intestinal, 206 

intestinal, 173, 200, 331 
Fetal circulation, 37 

conditions, persistent, 452 
Fetus, faulty development of, 450 

syphilitic. 742. 743 

typhoid fever in, 618 
Fever blister, 596. See Herpes Labialis. 

causes of, 41 

in otitis, 609 

inanition, 204 

obscure. 563 

quotidian, 733 

reduced by baths, 626 

rheumatic, 492 
Filix mas for tapeworm, 344 
Fingers, biting of, 223 

necrosis of, 521 
Fish, cooking of, 343 
Fish-skin disease, 589 
Fistula, anal, 329, 365 

blind, 367 

of neck, 86, 87 

of urachus, 89 

rectal, 94 
Flashes of heat, 855 
Flat-foot, 237 
Flatulence in infants, 272 
Flatus from indigestion, 318 
Flexner bacillus, 289 



874 



INDEX 



Flexner's serum, 707, 817 
Floating kidney, 562 
Flours, standardized, 157 
Fluid, body, loss of, 290 

cerebrospinal, 76 
Fluids, regurgitation of, 836 
Fomentations, 316 

Fontanelle, anterior, closure of, 34, 235 
palpation of, 47 

bulging of, 106, 108, 114 
Fontanelles as landmarks, 18 

distention of, 809 
Food, amount of, 45 

anaphylaxis, 203 

aspiration of, 837 

assimilation of, 246 

bacteria in, 202 

bolting of, 397 

composition of, 204 

elements, 153 

excess of fat in, 200 

fried, 320 

heated, 764 

in hot weather, 283 

indigestible, 274 

injuries, 199, 271 

iron requirement in, 158 

passage of, from stomach, 45 

patent, for infants, 176, 227, 240, 
317, 320 

salt in, 550 

solid, for infant, 183 

sterilized, action of, 196 
Foot-and-mouth disease, 252 
Foot-drop, 797, 838, 839 

tuberculosis of, 518 
Foramen ovale, 18 

closure of, 39 

passage of blood through, 38 
patent, 453 
Forceps delivery, 108 

cause of palsy, 111 
Foreign bodies, aspiration of, 407, 443 
in ear, 607 
in nose, 393 
Foundlings, farming out of, 67 

institutions for, 404 

measles among, 644 

mortality among, 64 
Fountain syringe, use of, 664 
Fowler's solution in chorea, 845 

neuritis from, 839 
Fractures, compound, 517 

during delivery, 109, 112 

green-stick, 236 

in rickets, 233 
Frauenthal and Manning's table, 788 
Freeman pasteurizer, 146 
Fremitus, hydatid, 389 

tactile, 48 
Frenkel's exercises, 780, 806, 838 
Frenum, lax, 249 

ulceration of, 250 
Fresh-air treatment of disease, 214, 423, 

428, 653, 692 
Friction rub, 435, 456, 494 



Friedreich's ataxia, 804 

Fright affecting mother's milk, 272 

cause of chorea, 841 
Fruit juices in rickets, 241 
Fruits, diuretic, 546 

in diet, 327, 328 

raw, 289 
Fuchs-Rosenthal method, 777 
Fumigation by calomel, 686 
Fungus, air-borne, 254 

cause of thrush, 253 
Funicular hernia, 358 
Funnel chest, 235 
Furunculosis, 592 

of ear, 610, 615 



Gait, scissors, 826 
staggering, 743 
steppage, 797, 838 - 
straddling, 576, 578 
waddling, 799 
Gall-bladder, obliteration of, 375 
Gall-stones in children, 378 
in infancy, 120 
passage of, 376 
Games, competitive, 333 
Gametocytes, 733 
Gangrene in measles, 649 
of appendix, 336 
of intestine, 323, 335 
of lung, 442 
of skin, 601 
of umbilical cord, 125 
of vulva, 580 
Gangrenous stomatitis, 257 
Gargles, 688 

Gas bacillus, a cause of diarrhea, 285 
caused by carbohydrates, 201 
eructations of, 299, 301 
expulsion of, 313 
in feces, 195, 210 
Gastralgia, 266 

treatment of, 267 
Gastric analysis, 304 
capacity, 186 
contents of infants, 193 
digestion, 185, 186, 190 
hemorrhage, 316 
indigestion, acute, 274 
chronic, 295 
fermentative, 299 
juice, hyperacidity of, 304 
in newborn, 19 
secretion of, 187 
mucosa, atrophy of, 296 
ulcer, 314 

and pylorospasm, 311 
in newborn, 315 
perforation of, 315 
treatment of, 315 
Gastritis, acute, 275, 276 
catarrhal, 276 
diet in, 278 



INDEX 



875 



Gastritis, acute, differentiation of, 277 
symptoms of, 276 
treatment of, 277 
chronic, 295 
diet in, 298 
differentiation of, 297 
etiology of, 295 
pathology of, 295 
symptoms of, 296 
treatment of, 297 
corrosive, 278, 279 
membranous, 276, 277 
suppurative, 276 
ulcerative, 276, 277 
Gastroduodenitis, 279 
Gastro-enteritis, acute, 279 

diagnosis of, 282 
hygiene in, 283, 285 
pathology of, 280 
prognosis in, 282 
symptoms of, 281 
treatment of, 283 
caused by bacteria, 285 
in diphtheria, 670 
treatment of, 285, 287, 294 
with nephritis, 540 
Gastro-enterostomy, 308 
Gastro-intestinal diseases, 151, 246 
as cause of death, 56 
caloric feeding in, 179 
mortality from, 60, 61 
sepsis, 123 
tract of infant, 152 
Gavage, 420, 838 
in infants, 148 
in meningitis, 814, 819 
Gelatin for hemorrhage, 127, 131, 316, 

489 
Generation, organs of, 852 
Genitalia, changes in, at puberty, 854 
cleanliness of, 575, 579, 582, 584 
manipulation of, 582, 584 
Genito-urinary tract, 525 
anomalies of, 532 
at birth, 20, 26 
Geographical tongue, 248 
German measles, 653. See also Rubella. 
Gestation, infection during, 739 
Gingivitis, 223 
Girdle pains, 782 
rachitic, 235 
Girl baby, care of breasts in, 118 
Girls, chorea in, 845 

development of, 853, 856 
masculine, 514 
pertussis in, 691, 692 
Gland, pineal, 516 

thymus, development of, 35 
Glands at puberty, 859 

ductless, diseases of, 493 

in newborn, 20 
encapsulated, 727 
enlargement of, 479 
inguinal, 577 

submaxillary, enlarged, 253 
tubular, 559 



Glands, tuberculous, 726 
Glandular extracts, 243, 515 
Glans penis, puncture of, 572 
Glossitis, desquamating, 248 

obstruction from, 248 
Glottis, edema of, 262, 402 

occlusion of, 404, 407 

spasm of, 694 
Glycerin as vermifuge, 351 
Glycosuria, 530 
Goat's milk, 178 
Goitre, acquired, 508 

at puberty, 857 

congenital, 508 

exophthalmic, 509 

in girls, 509 
Gonococci in urethritis, 570 
Gonococcus causing cystitis, 567 
Gordon reflex, 825, 827 
Graafian follicles, 854 
Graves's disease, 509 
Gravity cream, 169 
Green sickness, 477 

stools, 210, 273 
Grippe, la, 701. See also Influenza. 

pneumococcus, 702 
Growing pains, 457, 747, 749, 857 
Growth at puberty, 30, 33, 853 

of child, 30 

limitation of, 852 
Gruel, dextrinized, 149 
Guinea-pigs, inoculation of, 661, 823 
Gummata of liver, 387 

of spleen, 495 
Gums, bleeding, 377 

in scurvy, 765 

lancing of, 225 

purulent discharge from, 260 

ulceration of, 255 



Habit spasm, 844 
Habits, unclean, 511, 830 
Hair, congenital absence of, 598 

falling of, 632 

growth of, at puberty, 854 

scanty, 510 

stumps, 595 
Hand, accoucheur's, 848 

claw, 796, 804 

trident, 140 

writer's, 848 
Handling of babies, 768 
Hardening of body, 409, 465 
Hare-lip, 82 

in idiots, 831 

operation for, 83 

pathological anatomy of, 83 

treatment of, 83 
Harrison's furrow, 235 
Head in hydrocephalus, 77 

normal proportions of, 34 

of newborn infant, 18 

rolling of, 232 



876 



INDEX 



Headache in measles, 652 

periodical, 857 
Hearing, development of, 44 

impairment of, 398, 613 
by furuncle, 615 

in newborn, 21 
Heart, apex beat of, 446 

cavities of, 445 

circumference of, 445 

compensation in, 446 

dilatation of, 458, 504, 635 

diseases of, 445 

congenital, 447, 450 
functional, 446 
organic, 464 
symptoms of, 446, 456 

examination of, 447 

failure, 669 

hygiene of, 464 

hypertrophy of, 455, 663 

in diphtheria, 668 

in newborn, 38 

in septic infection, 123 

instability of, 446 

left, reserve power of, 458 

malformations of, 833 
congenital, 84 

muscle, weakness of, 447, 449 

paralysis of, 669 

rhythm of, 447 

size of, 445, 458 

sounds, reduplication of, 449, 456 

transposition of, 454 

tuberculous lesions of, 727 

valvular disease of, 372 

weight of, 445 

working power of, 448 
Heart's blood, bacteria in, 812, 813 
Heat, animal, production of, 155, 157 

centre in the young, 40 

summer, and diarrhea, 331 
Heating of house, 26 
Height, growth in, 853 

of children, 30 

normal, 33 
Hematemesis, 314 

serum treatment of, 314 
Hematogenic jaundice, 371 
Hematoporphyrin, 843 
Hematuria, 526 

from renal calculi, 555 

from tumor, 556 

idiopathic, 526 
Hemichorea, 843 

Hemiplegia, cerebral, differentiation of, 
828 

in purpura, 491 

infantile, 825 

spastic, 107 
Hemoglobin in anemia, 476 
in splenic, 483 

in blood, 472 

in rickets, 232 
Hemoglobinuria, 527 

epidemic, 128 

paroxysmal, 527, 528 



Hemolysis, excessive, 374 

toxic, 478 
Hemophilia, 487 

bleeding in, 126, 396 

operation in, 489 

sex influence in, 127 

simulated by purpura, 491 

transmission of, 68 

treatment of, 489 
Hemoptysis in tuberculosis, 732 
Hemopoietic system, 373 
Hemorrhage, capillary, 478 

from bowel, 627 

from nose, 395, 396 

from tonsils, 399 

from trivial cause, 488 

from ureter and urethra, 527 

gastric, 316 

in adenectomy, 400 

in jaundice, 120, 370 

in measles, 647, 650 

in newborn, 122, 126 

in scurvy, 763, 764 

in Winckel's disease, 128 

into adrenals, 514 

into nerve sheath, 697 

meningeal, 106, 108 

nasal, 665 

rectal, from polypi, 365 

spontaneous, 488 

transfusion for, 127 

umbilical, 125 

within kidney, 556 
Hemorrhagic diseases, 487 
Hemorrhoids, 365 
Hereditary ataxia, cerebellar, 805 
differentiation of, 805 
etiology of, 804 
pathology of, 804 
sensory disturbance in, 805 
spinal, 805 
Heredity, 68 

cause of nephritis, 542, 547 
of neurosis, 301 

in alopecia, 598 

in bilious attacks, 380 

in chorea, 842 

in disease, 487, 796, 802 

in rheumatism, 748 

influence of, in appendicitis, 336 
in hare-lip, 82 
in jaundice, 373 
on brain, 42 
on height, 30 

mixed, 740 
Hernia, congenital, 358 

diaphragmatic, 96 

differentiated from hydrocele, 98 

femoral, 359, 360 

gangrenous, 361 

in cretins, 511 

inguinal, 358, 359 

mortality from, 698 

of brain, 72 

operation for, 360, 361 

retention of, 91 



INDEX 



877 



Hernia, strangulated, 360, 361 

truss for, 360 

umbilical, 90, 511 
Herpes, forms of, 596 

labialis, 246, 417 

of nose, 417 

zoster, 597 
Hexamethylenamin in meningitis, 818 

in pyuria, 532 
Hiccough in peritonitis, 338, 352 
Hip- joint disease, 552 
Hirschsprung's disease, 92 
Hiss, leukocyte extract of, 612 
Hives, 588 
Hoarseness due to tumors, 406 

in syphilis, 741, 742 
Hodgkin's disease, 484 

enlarged glands of, 439 
simulated by adenitis, 497, 498 
Hookworm, 348 

disease in the South, 341 
treatment of, 349 
Hookworms in moist earth, 349 

transmission of, 349 
Horlick's malted milk, 328 
Horse serum, 128, 131, 314, 503, 677 
Hospital ward, disinfection of, 693 
for observation, 682 
ideal, 213 
Hospitals, empyema in, 436 

for infants, 64, 65 

infant mortality in, 212 
Hot applications in dysentery, 292 

compresses, 573 

fomentations, 533 

packs, 546, 637 
House disease, 414 
Human blood serum, 314 
Hutchinson's teeth, 761 

triad, 745 • 
Hydrocele, 98 

differentiated from hernia, 359 

in acute orchitis, 573 

of cord, encysted, 359 

sac, extirpation of, 99 
Hydrencephalocele, 72, 74 
Hydrocephalus, acute, 75 

associated with hydrencephalocele, 
74 
with myelocystocele, 103 
with rickets, 230 

chronic external, 75 
internal, 75 

congenital, 75 

diagnosis of, 76 

following meningitis, 817 

pathological anatomy of, 76 

prognosis in, 77 

simulating achondroplasia, 139 

treatment of, 77 
Hydrochloric acid as a bactericide, 188 
deficiency of, 197, 298 
in stomach, 45, 188 
Hydronephrosis, 561 

acquired, 561 

bilateral, 562 



Hydronephrosis, etiology of, 561 

intermittent, 562 

puncture of, 562 

traumatic, 561 
Hydroquinine in pertussis, 695 
Hydrotherapy for constipation, 329 

in pneumonia, 429 
Hygiene at puberty, 857 

in diphtheria, 675 

in gastritis, 298 

in rickets, 241 

of childhood, 216 

of infancy, 240, 284 

teaching of, 67 
Hymen, imperforate, 103 
Hyperacidity, gastric, 308 
Hyperemia, passive, 524 
Hypertrophy, cardiac, 455 

muscular, 799 

of pyloric sphincter, 305 
Hypodermoclvsis in cholera infantum, 
295 

in diarrhea, 286 

in sclerema, 136 
Hypospadias, 104 
Hypotonus, 774 
Hysteria at puberty, 857 

distinguished from asthma, 441 

in tetany, 847 

retention of urine in, 534 



Ichthyosis, 589 

Icterus, 369. See also Jaundice. 

mortality from, 698 

neonatorum, 118, 369 
Idiocy, 828 

amaurotic family, 829, 832 

in spastic paraplegia, 827 

malformations in, 831 

manifestations of, 830 

Mongolian, svmptoms of, 833 

syphilitic, 831 
Idiot ica thymica, 36 
Idiots, thymus gland in, 502 

training of, 832 

unclean, 830, 832 
Ileocolitis, chronic, 320 

symptoms of, 321 
treatment of, 322 

differentiation of, 282 
Illegitimacy as cause of infanticide, 5S 

rural and urban, 59 
Imagination, 772 
Imbecility, 828 

in masturbators, 583 
Imitative instinct, 772 
Immaturity as cause of death, 54 
Immunization in diphtheria, 674, 677, 679 
Impetigo contagiosa, 591 
bullosa, 601 

differentiated from herpes, 597 

simulated by varicella, 641 
Incontinence, fecal, 330, 333 



878 



INDEX 



Incontinence from worms, 345 
of urine, 534 

nocturnal, 536, 571 
reflex, 535 
Incoordination, test for, 843 
Incubator, use of, 138 
Indicanuria, 198, 530 
Indigestion, 267 

acute gastric, 274 
carbohydrate, 157 
cause of vomiting, 263 
fat, prolonged, 155 
stools in, 319 
sugar, 156 
Infant at birth, eyes of, 26 

genito-urinary system of, 20 
normal appearance of, 17 
proportions of, 17 • 
skin of, 17 
temperature of, 21 
boarding out of, 166 
deserted, care of, 50 
early training of, 26 
feeding, 141 

artificial, 178 

and breast, combined, 164 
by percentages, 167, 169 
requirements of, 152 
materials used for, 151 
on cow's milk, 141 
on raw milk, 146 
problems of, 152 
foods, composition of, 176 
hospital, modern, 65 
metabolism, 152, 196 
mortality, 50 

among bottle-fed, 65 
campaign in Yonkers, 63 
causes of, 55 

congenital, 60 
decrease in 64, 66, 67 
due to alcoholism, 59 
during childbirth, 51 

first month, 51 
in census of 1900, 65 
in manufacturing centres, 54, 57 
in rural districts, 52, 54 
in times of war, 62 
in United States, 51, 66 
influenced by social status, 50, 

52,53 
Jacobi's views on, 64 
prevention of, 59, 63 
overlying of, 59 
weight of, 30 
welfare stations, 62 
work performed by, 42 
Infanticide, 58 
Infantile muscular atrophy, 795 

paralysis, 784. See Poliomyelitis, 
Acute Anterior. 
Infarcts from emboli, 459 

uric acid, 111, 528 
Infection, acute, followed by leukemia, 
479 
by clothing, 707 



Infection, cause of meningitis, 820 

of nutritional disturbance, 203 

during delivery, 577 

from o'idium albicans, 254 

of mouth, 252 

of skin, 586 

transmission of, 121 
Infectious diseases, specific, 617 
Inflammation, pseudomembranous, 686 
Inflation of intestines, 326 
Influenza, 701 

bacillus of, 701, 705 

cough in, 702, 706 

diagn6sis of, 704 

diet in, 706 

differentiation of, 704 

endemic, 702 

epidemics of, 702 

exhaustion in, 706 

forms of, febrile, 704 

gastro-intestinal, 704 
nervous, 704 
respiratory, 703 

heart in, 705, 706 

morbid anatomy of, 702- 

mortality in, 706 

nephritis in, 703 

pandemic, 702 

pneumonia in, 703 

skin rashes in, 705 

symptoms of, 702 

treatment of, by drugs, 706 

vera, 702 
Influenzal meningitis, 812 

serum for, 814 
Inguinal canal, testes in, 97 

glands enlarged, 360 
Inhalations of steam, 402, 412, 430, 686 
Inhibition, function of, 772 
Inoculation, animal, 663 ■ 

intraperitoneal, 823 

smallpox, 714 

with measles, 642 
Insect bites, 489, 589 
Insects in ear, 607 
Insolation, 810 
Inspection in bronchopneumonia, 426 

in pleurisy, 434 

of children, 46, 455 
Institution babies, breast-feeding for, 166 

mortality among, 64, 65 
Intellect, development of, 28 
Intercostal spaces, rebound of, 468 
Intertrigo, 590 

Intestinal indigestion, chronic, 316 
congenital, 316 

intoxication, acute, 282 

residue, 303 
Intestines, small, absorption in, 190 

strangulated, 336 
Intestines, abnormalities of, 191, 323 

absorption in, 193 

amyloid disease of, 334 

atony of, 326 

atresia of, 93 

bacteria in, 195, 289, 332 



INDEX 



879 



Intestines, diseases of, 263 

obstruction of, 94, 334 
congenital, 334 
due to diverticulum, 89 

of infants, 190 

of newborn, 19, 45 

parasites in, 341 

peculiarities of, 190 

perforation of, 354 

position of, 326 

putrefaction in, 198 

tuberculous, 728 
Intoxication, intestinal, 282 
Intracranial disease, 840 
Intubation, 402 

in diphtheria, 682, 683 

in laryngeal obstruction, 688 

in pertussis, 694 

in thymic disease, 508 

instant death after, 683 

prolonged, 684, 685 

swallowing after, 683 

tube, expulsion of, 683 
Intussusception, 288, 323 

agonal, 324 

diagnosis of, 324 

differentiation of, 313 

forms of, 323 

in infants, 190 

simulating peritonitis, 353 
prolapse, 364 

specimen from, 325 

treatment of, surgical, 326 
Inunctions, olive oil, 850 

mercurial, 745 
Iritis, 754 
Iron in diphtheria, 676 

in vicarious menstruation, 581 

pigments, 478 

reaction, 529 

stored in the body, 158 
Irrigation by catheter, 579 

intestinal, 320 

nasal, 393, 664 

of spinal canal, 824 

urethral, 570 
Ischiorectal abscess, treatment of, 368 
Isolation for vulvovaginitis, 578 

in varicella, 641 
Itch mite, 604 
Itching in eczema, 587 

in jaundice, 371 

in pediculosis, 603 

in urticaria, 589 

in varicella, 642 



Jaundice, 369 

acholuric, congenital, 373 
catarrhal, 120, 369, 370 
due to obliteration of bile ducts, 100 
from gall-stones, 378 
hematogenous, 369, 371, 735 
hepatogenous, 369 



Jaundice in cirrhosis, 382 

in gastroduodenitis, 279 

in tumor, 388 

in Winckel's disease, 129 

obstructive, 369 

of newborn, 118 

treatment of, 371 
Jaw in rickets, 235 

swelling below, 496 
Jaw-bone, curettage of, 259 

necrotic, 256 
Jews, chorea in, 842 

idiocy in, 832 
Joint, flail, 522 
Joints, affected by antitoxin, 682 

ankylosis of, 758, 761 

blood effusions into, 488 

diseases of, 517 

gonococcal, 522 

fixation of, 524 

in purpura, 492 

in scarlet fever, 638 

in septic infection, 123 

inflammation of, 635 

suppuration in, 523 

syphilitic, 761 

tuberculosis of, 523, 761 
Jugular vein, collapse of, 468 

thrombosis of, 504 
Jugulars, pulsation of, 463 



Kaplan's test, 776 

Karyokinesis, 479 

Keratitis in smallpox, 711, 713 

interstitial, 745 

syphilitic, 743 
Kernig's sign, 774, 788, 811, 816, 821 
Kidney, abscess of, 551 

amyloid, 384 

capsule, splitting of, 551 

congestion of, acute, 539 

congenital cystic, 557, 558 

contracted, 541, 547 

cysts, 558, 559 
bilateral, 561 
treatment of, 561 

degeneration of, 623 

diseases of, 525 

floating, 494 

hemorrhage from, 526 

inflammation of, 545 

infection of, 541 

injury to, 551 

irritation of, 545 

large red and white, 547 

malformations of, 557 

movable, 562 

operations upon, 566 

pain in, 551 

pus in, 551 

pyogenic infection of, 551 

tissue, 559, 560 

toxins in, 545 



880 



INDEX 



Kidney, tuberculosis of, 553, 554 

tumor of, 373, 552, 555 
diagnosis of, 557 
etiology of, 556 
treatment of, 557 
Kidneys in diphtheria, 668 

in influenza, 703 

in septic infection, 123 

miliary tubercles in, 728 

of newborn, 20 

uric acid in, 554 
Klebs-Loeffler bacillus, 656, 660, 663, 665, 

677, 679 
Klumpke's palsy, 110 
Knee-braces, 585 
Knock-knees, 237, 244 
Koplik's spots, 645, 646, 648, 652 
Kyphoscoliosis, 804 
Kyphosis, 781 

in rickets, 236 

treatment of, 244 



Labia, atresia of, 103 

irritation of, 576, 578 

ulcer of, 580 
Labor, difficult, conditions following, 78, 

115 
Laboratory modification of milk, 167, 172, 

181 
Labyrinthitis, 611 

Lactation, nervous state during, 273 
Lactic acid bacteria, 145 

in buttermilk, 174 
in stomach, 45, 188 
Lactose, 179, 269 

in mother's milk, 270 
Ladd's percentage table, 171 
Lagophthalmus, 840 
Landry's ascending paralysis, 779, 783 
Lanugo, 17 
Laparotomy, exploratory, 353 

for ascites, 384 
Laryngismus stridulus, 404 
treatment of, 243 
Laryngitis, acute, 400 

symptoms of, 401 
treatment of, 401 

in measles, 648 

membranous, 648 

submucous, 403 
Laryngospasm, 233, 507 
Larynx, diphtheria in, 665 

diseases of, 400 

edema of, 400 

flapping sound in, 685 

foreign body in, 407 

in girls, 853 

in scarlet fever, 635 

membrane formation in, 685 

operations upon, 407 

papillomata of, 406 

serous infiltration of, 402 

spasm of, 233, 405, 507 



Larynx, spasm of, treatment of, 405 

stenosis of, 685 

tube in, 683 

tumors in, 406 

ulceration of, 685 
Lavage, gastric, 294 

in infants, 186 
Lead colic, 839 

line, 839 

neuritis, 839 
Leeches, 403, 611 
Legs, tenderness of, 765 
Lemonade in pneumonia, 429 
Leptomeningitis, 808 
Leucorrhea, 859 
Leukemia, 479 

blood in, 480 

lymphatic, 480 

myelogenous, 480 

pathology in, 479 

splenomyelogenous, 480 

symptoms of, 480 

treatment of, 482, 483 
Leukocyte count in appendicitis, 340 

extract, 422, 612 

in blood, 473 
Leukocytosis, 340, 474, 476 

as aid to diagnosis, 474 

in atrophy of liver, 377 

in measles, 647 

in pneumonia, 418 

in subphrenic abscess, 380 

in summer diarrhea, 281 
Leukopenia, 420, 474 

in splenic anemia, 484 

in summer diarrhea, 281 
Lice, forms of, 603 
Lieberkuhn's glands, 19 
Ligaments in rickets, 237 
Light, leukodescent, 616 
Lime in food, 228 

water in gastritis, 278 

in milk mixtures, 173, 182, 303 
Lipomatosis interstitialis, 795 
Lin-sucking, 222 
Lips, diseases of, 246 

ulcer of, 247 
Liquids, swallowing of, in diphtheria, 684 
Lithotomy, suprapubic, 569 
Lithuria, 528 
Little's disease, 826 
Liver, abscess of, 378 

acute yellow atrophy of, 376, 377 

adhesions of, 387 

amyloid, 384 

autopsy findings in, 386 

cells, fatty degeneration of, 385 

cirrhosis of, 381, 469 

congestion of, 372 

cysts of, 389 

decrease in size of, 377 

diseases of, 368 

displacement of, 435 

dulness, 368, 373 

enlargement of, 373, 384 

examination of, 368 



INDEX 



881 



Liver, fatty, 384 

fluctuation in, 379 

functional disorders of, 380 

hydatid disease of, 389 

in diphtheria, 668 

in jaundice of newborn, 118 

in newborn, 20 

in syphilis, 742 

iron in, 858 

location of, 368 

nutmeg, 372 

red-cell destruction in, 478 

secretory function of, 192 

size of, 192, 368 

syphilis of, 387 

tubercles in, 728 

tuberculosis of, 386 

tumors of, benign, 389 

malignant, 388 
weight of, 192 
Lockjaw in tetanus, 134 
Lordosis, 236, 799 

of lumbar vertebrae, 527 
Ludwig's angina, 634 
Lumbar puncture, 775, 778 
for enuresis, 538 
in hydrocephalus, 77 
in meningeal tuberculosis, 725 
in meningitis, 818, 824 
in nephritis, 546, 638 
in pachymeningitis, 810 
in pertussis, 696 
in tetanus, 135 
landmark for, 35 
technic of, 775 
Lungs, abscesses of, 442 
atelectatic, 115, 408 
compression of, 435 
diseases of, 414 

expansion of, after birth, 112, 115 
gangrene of, 442 
in diphtheria, 66S 
in septic infection, 122 
necrotic, 443 
of newborn, 20 
syphilitic, 742 
tuberculosis of, 721 
Lymph glands, abscess of, 498 

cervical, tuberculous, 498 
enlargement of, 484, 495, 497, 

504, 507 
in scarlet fever, 630 
suppuration in, 497 
syphilitic, 743 
tuberculous, 485, 726 
Lymph nodes, bronchial, tuberculous, 
720 
cervical, swelling of, 392 
hyperplasia of, 500 
iii rickets, 230 
inflammation of, 495 
retroesophageal, 262 
suppuration of, 635 
Lymphadenitis, bronchial, 727 
Lymphangioma, cystic, of neck, 87 
Lymphatic anemia, blood picture in, 485 
56 



Lymphatic anemia, differentiation of, 485 

pathology of, 4n"> 

treatment of, 487 
Lymphatics, suppuration of, 687 
Lymphocytosis, 474, 479 
Lymphosarcoma, 499 



M 



McBurney's point, 335, 337 
Macroglossia, 86, 249 
Magnesia, milk of, 330 
Main en griffe, 796, 804 
Malaria, 732 

anemia in, 736 
blood changes in, 733 

test in, 736 
chill in, 734 
diagnosis of, 736 
distribution of, 732 
double infection in, 733 
etiology of, 732 
forms of, chronic, 736 
intermittent, 734 
irregular, 735 
hot stage of, 735 
in tropics, 733 
in ntero, 732 
lesions of, 734 
nervous phenomena in, 735 
parasite of, 732, 733 

estivo-autumnal, 734 
quartan, 733 
tertian, 733. 734 
paroxysms in, 733 
pernicious, 733. 736 
Plasmodium of, 732 
prognosis in, 736 
prophylaxis of, 736, 737 
sweating in, 735 
transmission of, 733 
treatment of, 736. 737 
Males, disease transmitted by, 138 
Malformations, S24 

congenital, 72, 82, 69S 
of bile ducts, 119 
of esophagus, 88 
of tongue, 85 
in idiots, S31 
of anus, 94 
of brain, 72 
of nervous system, S03 
of spinal cord, 72, 100, 778 
Malnutrition, 199, 200 
affecting thymus, 504 
cause of anemia, 475 
prolonged, 763 
with cyanosis, 452 
Malposition of bowel, 95 
Malt soup, 176, 178 
Maltose, 179 

Mammals, milk of, 161, 167 
Mammary glands at birth. 21 

infantile, swelling of, 117 
of mother, 159 



882 



INDEX 



Mammary glands, stimulation of, 117 

Man, embryo of, 68 

Marasmus due to fat indigestion, 268 

fatal, 504 

thymus gland in, 36 
Mare's milk, 178 
Massage, abdominal, 93, 381, 386 

for constipation, 329 

in myotonia, 803 

in poliomyelitis, 794 
Mast cells, 473 
Mastication in mumps, 699 
Mastitis, etiology of, 117 

in nursing mother, 164 

of infants, 117 

treatment of, 118 
Mastoiditis, acute, 614 

complications of, 615 
operation for, 615 

bilateral, 616, 696 

in otitis, 610 

temperature in, 615 
Masturbation, 582 

due to worms, 345 

etiology of, 582 

followed by chorea, 842 

indican reaction in, 530 

in schools, 860 

manual, 583, 585 

mechanical prevention of, 585 

symptoms of, 583 

treatment of, 584, 585 
Maternity hospitals, 120 
Maxilla, deformity of, 391 
Measles, 642 

absence of, rash in, 647 

after diphtheria, 649 

among the poor, 651 

at end of uterogestation, 643 

blood in, 642 

complications of, 648 

desquamation in, 646, 647 

differentiated from rubella, 655 
from scarlet fever, 633 

digestive system in, 650 

epidemics of, 428, 643, 655 

eruption of, 633, 642, 645 

etiology of, 642 

eyes in, 644 

in early infancy, 643 

Koplik's spots in, 645, 648, 652 

laryngitis in, 648, 653 

malignant, 647 

membrane formation in, 662 

mortality in, 698 

nephritis in, 650 

nervous symptoms in, 650 

pathology of, 644 

prophylaxis in, 428, 651 

relapses in, 650 

sequelae of, 648 

severe forms of, 644, 647 

simulated by serum rash, 682 

stages of, 645 

susceptibility to, 643 

temperature in, 645 



Measles, treatment of, 652 

virus of, 642 
Meat, cysticerci in, 343 
dislike for, 511 
preparations, 177 
raw, as cause of rickets, 228 
Meatus, contraction of, 104 
Meckel's diverticulum, 88, 323 
Meconium, 194 
Megaloblasts, 473, 476 
Melena, complications of, 132 
etiology of, 130 
from gastric ulcer, 315 
in cirrhosis, 382 
neonatorum, 129 
prognosis in, 130 
Mellin's food, 328 
Membrane, diphtheritic, 656, 662 

false, 666 
Mendel-Bechterew's sign, 779 
Meninges, diseases of, 808 
Meningitis, acute, purulent, 810, 813 
suppurative, 810 

pathology of, 811 
stimulation in, 814 
symptoms of, 811 
treatment of, 813 
basilar, 820 
carriers of, 815, 818 
cause of hydrocephalus, 77 
cerebrospinal, 814 
contact in, 815 
dissemination of, 815, 818 
etiology of, 814 
immunity to, 818 
mortality in, 817 
pathology of, 815 
prophylaxis of, 818 
serum in, 818 
symptoms of, 815 
treatment of, 818 
epidemic, 814 
following otitis, 610 
in mumps, 701 
influenzal, 704, 810 
serum for, 707 
pneumococcic, 810, 812 
secondary otitic, 696 
septic, leukocytosis in, 474 
simulated by gastritis, 277 
staphylococcic, 812 
streptococcic, 810 
stupor in, 816, 821 
syphilitic, 725 

tuberculous, 75, 724, 728, 819 
diagnosis of, 823 
etiology of, 819 
pathology of, 820 
prophylaxis in, 824 
symptoms of, 821 
typhoid, 813 
vertical, 810 
with diarrhea, 282 
Meningocele, 72, 74 

spinal, 100 
Meningococci, intracellular, 817, 818 



IXDEX 



883 



Meningoencephalitis, 822 
Menstruation, 851 

and pylorospasm, 312 

early, 859 

first, 855 

in chlorosis, 477 

in nursing mother, 164 

precox, 581 

value of, 49 

vicarious, 581 
Mental brilliancy, 30 

capacity, transmission of, 71 

deficiency, 105, 140, 828 

in masturbation, 582, 583 

development, retarded, 106 

retrogression, 833 

stigmata, 830 
Mercury, bichloride, in diphtheria, 676, 
686 

in cirrhosis of liver, 383 

in syphilis, 388, 745 

poisoning by, stomatitis in, 256 
Mesenteric glands, tuberculosis of, 727 
Mesentery, traction on, 323 
Mesonephros attached to kidney, 557 
Metabolism, carbohydrate, 266 

fat, 199 

intermediary. 196, 199, 202, 206 

of infant, 32, 152, 160 
Metallic poisons, 256 
Metastasis from kidney tumor, 556, 557 
Meteorism, 208 
Microcephalus, 105 
Microcytes, 473 
Microglossia, 249 

Microlelia, 138. See a Jso Achondroplasia. 
Micturition, cramps in, 553 

normal, 525 
Migraine, 312 
Miliaria, 593 

Miliary tuberculosis, acute, 722 
Milk, albumin, 173 

bacterial decomposition of, 207 

boiled, 289 

cause of diarrhea, 331 

certified, 142. 147 

coagulation time of, 189 

colostrum, 159, 161 

Commission. 142. 169 

condensed, 150, 317 

crust, 593 

diet, undernourishment from, 461 

dispensaries, 63, 67 

dried, 176 

ducts, bacteria in, 118 

fat-free, 168, 180, 319 

fat in, 180, 268 

feces, contents of, 195 

formulas, 182 

granules, 195 

human, 161 

bacteria in, 121 

in dysentery, 292 

infection of, 60 

inspection, 67 

laboratory, 172 



Milk, mineral salts in, 158 

mixture, alkalinity of, 304 
at different ages, 182 
constituents of, 172, 181 
prescription for, 182 
modified, 147 
modifiers, 177 
pasteurized, 145, 729 

cause of scurvy, 764 
peptonized, 148 
preservation of, 143, 144 
protein, 173 
purity of, 283, 293 
skimmed, 269 
souring of, 143, 331 
sterilized, 144. 332 
sugar, 156 

absorption of, 197 
excess of. 207 
in infant feeding. 179 
tubercle bacilli in, 719 
tuberculin test for, 729 
withholding of, 298, 300 
Milk-teeth, absorption of, 220 

eruption of, 217 
Mind at puberty, 855 
Mineral salts, ingestion of, 157, 158 

metabolism of, 198 
Mitral insufficiency, 463 
regurgitation, 459 
stenosis, 459, 463, 857 
valve lesions, 4o ,s > 
Modification of milk. 167, 169, 172 
at home, 169, 172, 180 
in laboratory, 181 
Modified milk, caloric value of, ISO 
Mole, hairy, 600, 601 

malignant, 601 
Molluscum contagiosum, 602 
Mongolian idiocy, 829 

distinguished from cretinism, 
512 
Monkeys, poliomyelitis in, 784, 7S6 
Mononuclears, 473 
Monsters, absence of brain in, SO 

with ichthyosis, 589 
Monteau reaction, S23 
Moral characters, inheritance of, 68 

degeneration, 5S3, 5S5 
Morbilh. See Measles. 
Moro reaction, 730, 823 
Morse and Talbot's food table, 176 
Mortality at puberty. 856. S57 

from gastro-intestinal lesions, 52, 56 
from summer diarrhea, 331 
in appendicitis, 338 
in children under five, 51 
in diphtheria, 672. 679 
in fetal typhoid, 619 
in infants, bottle-fed, 51 
during war, 162 
illegitimate, 58, 59 
of factory women, 52 
under one year, 56 
in measles, 651 
in pyelitis, 566 



884 



INDEX 



Mortality in Ritter's disease, 602 
in scarlet fever, 628, 636 
in smallpox, 717 

table's, 53, 54, 624, 636, 651, 672, 
692, 698 
Mosquitoes, malaria transmitted by, 732 

737 
Mother, health of, 57 

pregnant, occupation of, 56 
syphilitic, 388, 746 
"Mothering" in hospitals, 65 
Mothers as factory workers, 215 
Mother's milk, 161 

advantages of, 208 
antibodies in, 166, 167 
failing secretion of, 162 
fat in, 200, 268, 303 
food, elements in, 184 
improvement of, 239 
lactalbumin in, 154 
mineral constituents of, 158 
protein in, 154 
pumping of, 319 
substitutes for, 178 
sugar in, 269 
Motor excitability in infants, 43 
functions, 771 
irritation, 821 
responses, 771 
Mouth, bacteria in, 686 

breathing, 47, 391, 397, 835 
care of, 26, 183 
diseases of, 249 
disinfection of, 701 
fissures about, 740 
fungus in, 253 
hygiene of, 252, 254 
in facial palsy, 840 
in septic infection, 122 
inflammation of, 251 
of newborn, 19 
necrosis of, 258 
ulcers in, 251, 259 
Mucosa, gastric, in rickets, 230 
healthy, 392 
nasal, 395 
Mucous colitis, 333 

membrane, bronchial, 223 
in infancy, 219 
in rickets, 233 
in summer diarrhea, 280 
nasal, inflammation of, 297 
oral, 223, 251, 255 
pigmentation of, 515 
syphilitic, 742 
tympanic, 607 
patches, 740 
Mucus in stools, 211, 280 
Multiple neuritis, 835 

non-diphtheritic, 838 
toxic, 839 
Mumps, 699 

complications of, 700 
diagnosis of, 700 
in pancreatitis, 389 



Mumps, isolation in, 701 

recurrent, 700 

simulated by adenitis, 496 

susceptibility to, 699 

symptoms of, 699 

treatment of, 701 

urine in, 700 
Murmurs, accidental, 459 

blowing, 457 

cardiopulmonary, 448 

endocardial, 458 

from debility, 449 

functional, 448, 460 

hemic, 475, 477 

in chorea, 843 

in school children, 448 

mitral, 635 

musical, 450 

myocardial, 621 

organic, 462 

presystolic, 459 

pulmonary systolic, 448 

systolic, 450, 453, 635, 857 

transient, 635 
Muscle atrophy, 795 

changes at puberty, 857 

sense tracts, 43 

spasms, 806 

tissue, irritability of, 302 
Muscles, facial, in chorea, 843 

impaired, 832 

stimulation of, 802 

trichinae in, 350 

weakness of, 237 
Muscular development, 41 

dystrophy, progressive, 798 

insufficiency, 470 

weakness, congenital, 803 
Mustard bath, 295, 429 

pack, 429 

paste, 412,. 421, 429 
Mutilations, 830 
Myelin in nervous system, 43 
Myelinization in spinal cord, 770 
Myelitis, 779 

compression, 779 

due to caries, treatment in, 783 
to Pott's disease, 782 

paralysis in, 782 

relapses in, 782 

transverse, 779 
lesions of, 780 
picture of, 782 
symptoms of, 779, 780 
treatment of, 780 
Myelocystocele, 101 
Myelocytes, 474, 479 
Myelomeningocele, 101, 103 
Myocardial insufficiency, 469 
Myocarditis, 464, 469, 650 

diagnosis of, 470 

diphtheritic, 470 

low-grade, 468 

rheumatic, 756 

stimulation in, 471 

treatment of, 470 



INDEX 



885 



Myositis, 757 
Myotonia congenita, 802 

Oppenheim's, 803 
Myringotomy, 611, 637 



N 



X.evi, 600, 857 
Nageli, experiments of, 70 
Nail, claw-shaped, 47 
Nails, shedding of, 632 
Nares, packing of, 396 
Nasal discharge as a symptom, 47 
douche, 394 

passages, disinfection of, 393 
occlusion of, 391 
Nasopharynx, diplococcus in, 815 
diseases of, 391 
in diphtheria, 664 
in meningitis, 818 
in pertussis, 693 
mucopus in, 438 
Nausea, postanesthetic, 308 
Neck, congenital diseases of. 86 
cystic lymphangioma of. 8 i 
rigidity of, 816 
Necrosis of finger or toe, 521 
Negroes, rickets among, 228 
Neisser's staining method, 657 
Nematodes, 344 

Neoplasms a cause of stenosis, 376 
Nephrectomy for hydronephrosis, 562 
for tumor, 557 
for renal tuberculosis, 554 
Nephritis, 538 

acute, conyalescence from, 546 
pathology of, 542 
prognosis of, 544 
prophylaxis of, 545 
treatment of, 544 
albuminuria in, 54S 
anuria in, 532 
caused by drugs, 542 
chronic, 547 

edema of larynx in, 402 
interstitial, 550 
pathology of, 547 
parenchymatous, 54S 
diet in, 550 
operation in, 551 
symptoms of, 54S 
treatment of, 550 
urine in, 548 
complications of, 540, 544 
diet in, 545 
diffuse, 540 
diphtheritic, 539 
exudatiye, 543 
fulminating, 543 
gastro-intestinal, 540 
in diphtheria, 660, 668 
in infancy, 539 
in measles, 650 
in purpura, 492 
in varicella, 641 



Nephritis, parenchymatous, 540 
pathology of, 540 
primary. 540 
puffiness in, 543 

scarlatinal, 539, 541, 543, 634, 637 
symptoms of, 543 
syphilitic, 540 
toxic, 539, 542 
transmission of, 542 
urinary changes in, 543 
Ncrye, facial, 839 

roots, irritation of, 782 
trunk, eruption along, 597 
Neryes, diseases of, 835 
peripheral, 770 

changes in, 836 
stimulation of, 774, 775 
Nervous equilibrium. 571 
in. central, 769 
bacteria in. 77 
malformations of, 803 
organic lesions of. 830 
deyelopment of. 42. 769, 858 
examination of. 772 
histological structure of. 769 
in cerebral palsy, 826 
in diphtheria, 668 
in infancy. 219 
in nephritis, 540 
in newborn, 21. 769 
in scarlet fever. 635 
morphology of, 769, 771 
of child. 771 
peculiarities of. 771 
Nettle rash, 588 
Neuralgia in herpes zoster. 597 

occipital, 782 
Neurasthenia at puberty, 858 
Neuritis from lead, 839 
multiple, 835 
peripheral. 792 
Neurotic children. 447. 449 
Newborn, asphyxia of, 112, 113 
bathing of.' 22 
circulation in, 18 
deformities of, 72, 450 
digestive system of, 19 
diseases of, 105 
erysipelas of, 131 
exfoliation of, 602 
hematuria in, 526 
hemorrhage in, 126, 375 
laryngeal stridor in, 405 
leukocytosis in. 473 
measles in. 643 
modified milk for, 181 
mouth of, 184 
otitis media in, 608 
peritonitis in, 351 
proportions of, 17 
respiratory system in, 20 
rhinitis in. 395 
septic infection of, 120 
syphilitic liver in, 387 
urinary findings in. 111 
vomiting in, 263 



sm 



INDEX 



Newman's mortality tables, 53, 54 
Night sweats, 433, 523 

terrors, 330, 523, 752 
Nipple, bleeding from, 129 

care of, 160 

fissured, 283 

injury to, 220 

shield, 183 
Nipples, artificial, care of, 183, 223, 254, 
283 

rubber, shape of, 251 
Nisserian infection, 578 
Nitrate of silver in pertussis, 693 
Nitrogen in feces, 195 
Nodules, rheumatic, 747, 751 
Noguchi reaction, 744 
Noma, 257. See also Stomatitis, Gan- 
grenous. 

vulvae, 580 
Normoblasts, 473, 476 
Nose as seat of diphtheria, 660 

congenital defects in, 391 

foreign body in, 393 

membrane formation in, 662 

passage of food into, 669 

picking at, 345, 347 

regurgitation from, 663 

saddle-shaped, 139 
Nosebleed, 395, 462 

in diphtheria, 662 
Nourishment by rectum, 316 

in typhoid, 625 
Nozzle, rectal, use of, 366 
Nucleo-albumin in urine of newborn, 111 
Nurse, clothing of, 636 

girls, 577, 583 
Nursery, 23, 25 
Nurses, visiting, 67 
Nursing bottle, care of, 183, 223, 283 

in diphtheria, 673 

in myocarditis, 470 

mother, food for, 57, 271 
hygiene for, 159, 240 
Nutrition, disturbance of, 202, 203 

faulty, a cause of scurvy, 763 
of skin disease, 593 
Nystagmus, 107 



Obstetric paralysis, 108, 111, 839 
Obstruction, intestinal, 94, 299, 334 

of esophagus, 88 

of pylorus, 302 

portal, 357 
Occupation a factor in disease, 815 

effect of, 215, 216 
Ocular palsies, 789 
Odor in diphtheria, 662 

in noma, 258 

of stools, 195, 210, 273 
O'Dwyer's intubation, 682, 685 
Oi'dium albicans, 253 
Oil in ear, 611 
Oils, digestion of, 200, 304 



Oils, mineral, 330 

Olive oil as cathartic, 330 

in infant's food, 179 
injections, 328 
inunctions, 241 
Olshausen's operation, 90 
Omphalitis, 124, 125 
Ophthamia, diphtheritic, 667 
from vulvovaginitis, 578 
vaccinal, 713 
Opisthotonos, cervical, 816 

in meningitis, 816, 817, 820 
in pneumonia, 419 
in tetanus, 133 
Oppenheim's myotonia congenita, 803 
reflex, 770, 773, 779, 782, 797, 806, 
825, 827 
Optic chiasm, hemorrhage at, 697 

nerve atrophy, 805, 826 
Oral cavity, 184, 185 
Orange juice for infant, 147, 183 

in scurvy, 767, 768 
Orchitis, 570, 573 
in mumps, 700 
syphilitic, 573 
tuberculous, 573, 859 
Organs of special sense, 21 
Oropharynx in uvulitis, 261 
Ossification, endochondral, 138 

of bone, 231 
Osseous canal, drooping of, 615 
Osteomyelitis, acute infectious, 517 
pathology of, 517 
simulating rheumatism, 753 
rarefying, 520 
Osteoperiostitis, tuberculous, 522 
Osteotomy in rickets, 244 
Otitis media, 398, 840 

acute, catarrhal, 607 

purulent, 224, 607 
after diphtheria, 608 
bacteriology of, 608 
bilateral, 649 
chronic suppurative, 612 
complications of, 610, 808 
differentiation of, 313, 610 
in bronchopneumonia, 427 
in diphtheria, 666 
in measles, 649 
purulenta, 609 
scarlatinal, 635 
suppurative, 614 
symptoms of, 608 
treatment of, 611, 637 
Otorrhea, 614 
Outdoor life for infant, 25 

treatment of disease, 212 
Overeating, 858 
Overfeeding, 204, 317 

cause of fatty liver, 386 
in pneumonia, 420, 428 
Overwork at puberty, 857 
Ovulation, 853 
Oxidation, excessive, 198 
Oxygen, inhalation of, 138, 422 
for asphyxia, 114 



INDEX 



887 



Oxygen in pernicious anemia, 483 
in pneumonia, 429, 430 

Oxygenation, deficient, 451 
of blood, 38 

Oxyuris vermicularis, 344 

Oysters, infection from, 617 



Pachymeningitis externa, 808 
interna, 808 

hemorrhagica, 808, 820 

differentiation of, 809 
purulent, 808 
serum in, 810 
symptoms of, 809 
treatment of, 810 
Pack, hot mustard, 413 
Pad, vulvar, 580 
Pain from renal calculi, 554 
insensibility to, 44 
lumbar, 551 
on urination, 568, 570 
Palate, 391, 831 
Pallor from aortic disease, 456 
in anemia, 475 
in heart disease, 456 
in pseudoleukemia, 481 
Palpation, 47, 455 
in pleursy, 434 
of kidney, 563 
of spleen, 493 
Palpitation, cardiac, 462 
Palsy, bilateral, 111 
cerebral, 792, 824 
Klumpke's, 110 
obstetrical facial, 111, 839 
ocular, 837 
Pancreas, diseases of, 389 
function of, 45 
in syphilis, 742 
tuberculosis of, 390 
Pancreatic juice, 192, 193 
Pancreatitis, acute, 389 
Paralysis, acute ascending, 783 
cardiac, 507 

diphtheritic, 669, 678, 836 
atrophy in, 837 
nerve changes in, 836 
pathology of, 836 
prognosis in, 837 
speech in, 836 
symptoms of, 836 
treatment of, 838 
facial, 111, 611, 839 

obstetrical, 111, 839 
symptoms of, 840 
treatment of, 841 
flaccid, 790, 825 

from spinal cord tumor, 101, 103 
in idiots, 831 
in meningitis, 822 
in muscular atrophy, 795 
infantile, distribution of, 789 
Landry's, 783 



Paralysis, natal, 108 

of arms and legs, 838 

of extremities, 807, 840 

of newborn, 105, 106 

of phrenic nerve, 837 

postdiphtheritic, 238, 673 

prenatal, 105 

pseudohypertrophic muscular, 799 

respiratory, 670, 838 
Paranephritis, 551 
Paraphimosis, 572 
Paraplegia from birth injury, 112 

spastic, 826 
Parasite, malarial, 733 

segmentation of, 733, 734 
Parasites, animal, 603 

cause of anemia, 478 
of colic, 313 

in scalp, 594 

intestinal, 474 

vegetable, 603 
Parathyroid extract, 850 
Paratyphoid bacillus, 624, 627 

fever, etiology of, 627 
Parotid gland, suppuration of, 700 
Parotitis, epidemic, 699. See also 

Mumps. 
Pasteurization of milk, 145, 283 
Pavor Qocturnus, 397 
Pediculosis capitis, 495, 603 

corporis, 603, 604 

pubis, 603 

with eczema, 587, 58S 
Pellet ierin, 344 
Pelvis, deformity of, 236, 244 

in the sexes, 853 
Pemphigus, 741 

neonatorum, 601 

simulated by varicella, 640 

syphilitic, 601 
Penis, infantile, 516 
Peptonization of milk, 148, 273, 285 
Percentage feeding, 167, 172 
Percussion, 49, 455 

in lobar pneumonia, 415 
Pericardial sac, obliteration of, 466 

puncture of, 467 
Pericarditis, 650 

acute, 465 

from rheumatism, 465, 467 
prognosis of, 466 
symptoms of, 465 
treatment of, by rest, 467 

adherent, 467, 468 

complicating endocarditis, 460 

morbid anatomy of, 468 

operation in, 467 

purulent, 466 

treatment of, operative, 466 
Pericardium, tubercles on, 727 
Perinephritis, 551 

Periosteum, fibrous ingrowth of, 139 
Periostitis from infection, 517 
Perisplenitis, 494 
Peristaltic waves, 302, 307, 312 
Peritoneum, diseases of, 351 



INDEX 



Peritonitis, abscess in, 353 

acute, 351 

bacilli in, 352 
etiology of, 351 
symptoms of, 352 

ascites in, 355 

chronic, 354 

non-tubercular, 355 
treatment of, 356 

circumscribed, 353, 354 

from kidney tumor, 556 

from rupture of appendix, 338 

gonorrheal, 353 

operation in, 354 

plastic, 353 

pneumococcal, 352, 353 

suppurative, 352 

traumatic, 353 

treatment of, 353, 354 

tuberculous, 728 

simulating Addison's disease, 
515 
Perleche, 247 
Pernicious anemia, 478 

blood picture of, 341, 478 
color index in, 482 
treatment of, 483 

malaria, 736 
Perspiration, 398, 509 

in rickets, 232 
Pertussis, 688 

bacilli in nasopharynx, 693 

belt for, 695 

catarrhal stage of, 688, 689 

cause of prolapse, 363 

complications in, 690, 694, 696 

diagnosis of, 691 

diet in, 693 

epidemics of, 688 

in diphtheria, 669 

in females, 691 

in measles, 650 

in young infants, 688 

isolation in, 692 

hemorrhages in, 690 

leukocytosis in, 474 

local applications in, 693 

mortality from, 691, 692, 698 

paroxysms in, 689, 696 

pathology of, 689 

prognosis in, 691 

prophylaxis in, 428, 697 

psychic phenomena in, 690, 696 

stages of, 689, 690 

susceptibility to, 688 

toxin produced by, 689 

treatment of, 692, 694 
vaccine, 697 

whoop in, 688 
Pes cavus, 825 

equinus, 800 

varus, 798 
Petit mal, 456 
Petroleum sprays, 737 
Pets as carriers, 629 
Peyer's patches, 288, 290, 617 



Pfeiffer's bacillus, 701 
Phimosis, 571, 846 . 

operation for, 99 

cause of cystitis, 567 
of retention, 533 

treatment of, 571 
Phlebitis, septic, 121, 122 
Phosphorus in rickets, 242 
Photophobia, 21, 645, 816, 822 
Phthisis, pneumonic, 724 
Physical characters, inheritance of, 68 

exercise, excessive, 464 
Pigeon-breast, 37, 229, 235 
Pigment in nervous system, 43 

urinary, 371 
Pigmentation, 514 

due to poisons, 515 

malarial, 734 
Pineal gland, 516 
Pituitary extract, 516 

gland, 516 
Plane warts, 598' 
Plasmodium malarise, 732 

hyaline forms of, 734 
Plaster bandage in pertussis, 696 
Plastic operation for Erb's palsy, 110 

for spina bifida, 103 
Plethora in newborn, 19 
Pleura, aspiration of, 438 

diseases of, 430 

drainage of, 436, 437 

irrigation of, 437 
Pleural effusion, differentiation of, 435 
gravitation of, 434 
puncture of, 435 
treatment of, 436 
Pleurisy, bacteriology in, 431 

circulation in, 433 

convalescence from, 438 

cough in, 433 

diaphragmatic, simulating appendi 
citis, 339 

dry, 433 

fever in, 432 

following pneumonia, 431 

pain in, 433 

palpation in, 434 

pathology of, 431 

percussion in, 434 

physical signs of, 434 

primary, 432 

purulent, 430 

respirations in, 433 

serous, 430 

symptoms of, 432 

tuberculous, 727 
Pleurodynia, 757 
Pneumococci, 414, 422 
Pneumococcic meningitis, 812 
Pneumogastric nerve, pressure on, 447 
Pneumonia, 414 

aspiration, 635, 784, 837 

cause of infant mortality, 63 

differentiation of, 419 

family tendency to, 414 

in diphtheria, 669 



INDEX 



889 



Pneumonia in influenza, 703 
in measles, 649, 653 
leukocytosis in, 474 
lobar, '414, 669 

clinical picture of, 417 
convalescence from, 423 
crisis in, 418 
diagnosis of, 418 
differentiation of, 419 
in measles, 649 
morbid anatomy of, 415 
physical signs of, 415 
stimulation in, 421 
symptoms in, 416 

cerebral, 419, 424 
gastro-intestinal, 418 
nervous, 419, 422 
treatment of, 420 
masked by other diseases, 419 
mortality from, 698 
postoperative, 407 
prognosis in, 420 
rheumatic, 752 
right-sided, 339 
treatment of, outdoor, 213 
Pocks, vaccination, 716 
Poikilocytes, 473, 476, 479 
Poisoning, lead, 839 
Poisons a cause of hemoglobinuria, 527 

swallowing of, 262 
Poliomyelitis, abortive, 784, 786, 791 
acute anterior, 784 

age of onset, 785 
carriers of, 786, 793 
cellular infiltration in, 786 
contractures in, 794 
deformity in, 791 
differentiated from Erb's 

palsy, 107, 109 
disinfection in, 793 
dissemination of, 785 
epidemics of, 785 
etiology of, 785 
experimental study of, 784 
history of, 784 
idiocy in, 829 
immunity to, 786 
incubation period in, 787 
meningitis in, 788 
muscles in, 787, 790 
nervous system in, 787 
pain in, 793, 794 
paralysis in, 788 
pathology of, 786 
prodromes of, 788 
prophylaxis of, 793 
quarantine in, 793 
recovery from, 793 
spinal fluid in, 788 
symptoms of, 787 
treatment of, 793 
by drugs, 794 
surgical, 794 
trophic disturbances in, 
790 
bulbospinal, 791 



Poliomyelitis, cerebral, 791 
clinical, 783 
diagnosis of, 791 
differentiation of, 792 
epidemic, 792, 793 

mortality in, 792 
infectious organism of, 784, 785 
simulating scurvy, 767 
spinal fluid in, 791 
Pollakiuria, 534, 567 
Polyarthritis, chronic, 758 

in purpura, 492 
Polychromatophilia, 476, 479 
Polycythemia, 451 
Polynuclears, 473 
Polypi, 364, 365 
Polyserositis, 381 
Polyuria, 534 
Pools, draining of, 737 
Porencephalus, 105 
Pork, inspection of, 343 
Posterior nares, diphtheria of, 673 
Posture, significance of, 47 
Potassium citrate in cystitis, 568 
Pott's disease, 384, 781 

deformity from, 552 
differentiated from rickets, 236 
Poultices in pneumonia, 421 
Poverty, as cause of rickets, 227 
of summer diarrhea, 280 
late development in, 855 
Precocity, psychic, 516 
Precordia, bulging of, 455, 458, 462 
Pregnancy, blood during, 117 
care during, 67 
depression in, 450 
early, 859 

nourishment during, 239 
Premature infants, feeding of, 182 
Prematurity as cause of death, 57, 60 
Prepuce, orifice of, 571 
Pressure, intra-abdominal, 358 
intracranial, 808 
intralaryngeal, 685 
Procidentia recti, 362 
Proctitis, 361 

catarrhal, 361 
gonorrheal, 361, 362 
treatment of, 362 
Proctoclysis, saline, 340 
Progressive muscular atrophy, 795 
adult type, 796 
hereditary, 797 
infantile spinal, 795 
lateral sclerosis in, 797 
neural form, 795, 797 
peroneal, 797 
spinal, 795 
dystrophy, 798 
atrophic, 801 
hereditary, 801 
infantile, 801 
juvenile, 801 
treatment of, 802 
types of, 798 
Prolapse of rectum, 290, 362 



890 



INDEX 



Prolapse of rectum from straining, 290 
in ileocolitis, 321 
in summer diarrhea, 281 
Proportions, puerile, 852 
Proprietary foods a cause of scurvy, 764 
Protein, digestion of, 192, 193 

disintegration, 530 

in cow's milk, 149 

in flours, 157 

in food, 154 

indigestion, 201, 271, 273 

milk, 173 

percentages, 171, 173 

variety of, 178, 179 
Proteus fluorescens, 369 
Protozoon as cause of scarlet fever, 629 
Pruritus due to fistula?, 367 

to worms, 345 
Pseudoankle-clonus, 773 
Pseudobacilli, 661 

Pseudocrises in pneumonia, 418, 422 
Pseudodiphtheria, 686 

antitoxin in, 687 

treatment of, 688 
Pseudohypertrophic muscular paralysis, 

798 
Pseudoleukemia, 484 

of infants, 481, 483 

of influenza, 481 

of von Jaksch, 373 

simulated by adenitis, 499 

spleen in, 482 
Pseudomembrane in intestine, 333 

non-adherency of, 687 
Psoas abscess, 552 
Psoriasis, 587, 594 
Psychical changes at puberty, 856 

during pregnancy, 510 
Ptomain poisoning, 593 
Ptyalin, 185, 191 
Puberty, 851 

breasts at, 854, 859 

circulation at, 854, 857 

cough of, 438 

development at, 852 

digestive system at, 858 

early, 28, 855 

effect of, on cyclic vomiting, 265 

epistaxis at, 395 

genitalia at, 854 

general health at, 856 

glandular system at, 859 

growth at, 30, 33 

heart disease at, 463 

morbidity at, 856, 857 

nervous system during, 858 

phenomena of, 855, 859 

premature, 859 

respiratory system at, 858 

thoracic changes in, 37 

thymus gland at, 499 

urinary disorders at, 858 
Pulmonary artery, abnormal, 452 

tuberculosis, 722 
caseous, 427 
Pulsation, cardiac, 455 



Pulse, dicrotic, 621 

frequency of, 39 

in childhood, 446 

in jaundice, 370 

in myocarditis, 469 

in pericaditis, 467 
Puncture, cerebral, 809 

for laryngeal edema, 403 
Punctures, spinal, 823 
Pupils, dilated, 419 
Purgation in cirrhosis, 383 

in gastritis, 277 
Purin substances, 529 
Purpura, abdominal, 492 

differentiation of, 490 

etiology of, 489 

fulminans, 490, 491 

hemorrhagica, 491 

typhoid state in, 491 

Henoch's, 492 

in adrenal disease, 514 

in splenic anemia, 483 

pathology of, 490 

rheumatica, 492, 751 

symptoms of, 490 

treatment of, 491 

variolosa, 709 
Pus, evacuation of, 523 

fetid, in cavities, 530 

from bronchioles, 424 

from urethra, 570 

gonorrheal, 577 

in ear, 609, 696 

in kidney, 551 

in nasal cavity, 395 

in peritoneum, 352 

in pleura, 437 

in stools, 273 

in urine, 565 

pyogenic, 524 
Putrefaction, intestinal, 198 
Pyelitis, 563, 564 

due to bacteria, 564 

etiology of, 564 

from trauma, 564 

prognosis in, 565 

relapses in, 566 

symptoms of, 564 

treatment of, by operation, 566 
by vaccines, 566 

tuberculous, 565 
Pyelocystitis, 563 
Pyelonephritis, 563, 565 
Pyelonephrosis, 563 
Pyemia from joint infection, 523 

of joint, 522 
Pyloric stenosis, congenital, 308, 310, 311 
hypertrophic, 302, 305 
diagnosis of, 306 
following measles, 310 
pathology of, 306 
recovery from, 311 
symptoms of, 306, 310 
in older children, 308, 311 
latent, 311 
organic, 309 



INDEX 



891 



Pyloric stenosis, treatment of, medical, 
309 
surgical, 307, 309, 311 
vomiting in, 264 
Pyloroplasty, 308 
Pylorospasm, 301 

artificial, 311 

at menstrual period, 312 

causes of, 309, 312 

diagnosis of, 302 

diet in, 303 

symptoms of, 302 

treatment of, 303, 305 
Pylorus, dilation of, 308 

hypertrophy of, 301 

passage of food through, 187 
Pyonephrosis, 531 
Pyorrhea alveolar is, 260 
Pyramidal tract, 773 
Pyuria, 531 

in pyelitis, 565 



Q 



Quarantine for cerebrospinal meningitis, 
818 

for diphtheria, 661, 663, 673, 675 

for infantile paralysis, 793 

for measles, 651 

for pertussis, 692 

for rubella, 656 

for scarlet fever, 630, 636 

for vulvovaginitis, 579 
Quincke's lumbar puncture, 775 
Quinine in malaria, 736, 737, 738 

in pertussis, 694, 695 



R 



Race suicide, 57 

Rachischisis, 779 

Rachitis. See Rickets. 

Radium for angioma, 601 

Ranula, 86 

Rape, 575 

Rash due to drugs, 648 

from antitoxin, 680, 681, 682 

in newborn, 26 

scarlatinal, 638, 639 
Ratio, cardiorespiratorjr, 417 
Reaction, agglutinin, 627 

of degeneration, 774 

tuberculin, 729 
Rectal tube, use of, 626 
Rectum, ballooning of, 328 

casts of, 362 

diseases of, 361 

early control of, 26 

fistula of, 94 

fixation of, 364 

polypi in, 364 

position of, 363 

prolapse of, causes of, 363 
treatment of, 364 



Rectum, worms in, 344 

Reeducation movements, 780, 794, 806, 

838 
Reflex cough, 438 
excitability, 847 
half-voluntary, 696 
irritation, 841 
Reflexes, abnormal, 773 
examination of, 770 
in infancy, 43 
normal, 773 
stimulation of, 771 
Regurgitation, 264, 268 
Elena] calculi, 554 

composition of, 554 
impacted. 555 
passage of, 555 
symptoms of, 554 
treatment of, 555 
disease, pulse in, 455 
hyperemia, 539 
insufficiency, 558 
tuberculosis, primary, 553 
Rennet, clotting of, 150 

coagulation, 189 
Kennin, 45, 175, 189 
Reproduction, power of, 450 
Reproductive organs, diseases of, 571 

system, 853 
Resistance, lowering of, 392 
Respiration affected by thymus, 505 
artificial, in asphyxia, 114 
audible, 505 

in bronchopneumonia, 425 
during infancy, 39 
stammer of, 405 
Respiratory centre, paralysis of, 116, 790 
stimulation of, 112, 113 
toxemia of, 425 
failure, 411 

tract, anomalies of, 391 
at birth, 20 
chronic catarrh of, 729 
diseases of, 391 
in measles, 64S 
in rheumatism 752 
Rest in heart disease, 470 
Restlessness in rickets, 237 
Retro-esophageal abscess, 262 
Rhagades, 247, 744 
Rheumatism, 747 

acute articular, 747 

acid sweats in, 749 
blood in, 751 
climate in, 756 
complications of, 754, 756 
convalescence from, 756 
diagnosis of, 752 
diet in, 755, 756 
differentiation of, 753 
heart in, 753, 756 
in older children, 750 
joint effusion in, 749 
lesions in, 750, 751 
nervous phenomena in, 752 
pain in, 750, 755 



892 



INDEX 



Rheumatism, acute articular, pathology 
of, 748 
prophylaxis in, 756 
symptoms of, 747, 749, 751 

extra-articular, 750 
toxins of, 749 
treatment of, 754, 755 
urine in, 749 

cause of endocarditis, 457, 462, 464 

chronic, 758 

etiology of, 748 

from malassimilation, 748 

infectious, 748 

muscular, 757 

nervous theory of, 748 

recurrent, 748, 750 

simulated by scurvy, 767 

treatment of, by baking, 762 

with chorea, 841 
Rheumatoid arthritis, 759 
diagnosis of, 760 
infectious, 759 
treatment of, 761 
Rhinitis, acute, 391 

due to bacteria, 392 
prophylaxis of, 393 

atrophic, 395 

chronic, 394 

hypertrophic, 394 

purulent, 395 

simulated by diphtheria, 662 

syphilitic, 746 
Rhubarb in constipation, 329 
Rhythm, respiratory, 39 
Ribs, resection of, 437 
Rickets, 227 

acute, 245 

adolescent, 245 

anemia in, 242 

blood in, 232 

causes of, 227, 229 

chest in, 233, 235 

complications in, 243 

congenital, 245 

convulsions in, 243 

craniotabes in, 522 

deformity in, 229, 233, 235 

dentition in, 221 

diagnosis of, 237 

differentiated from bone syphilis, 
520 

digestive disorders in, 243 

diseases intercurrent with, 239 

distinguished from cretinism, 512 

due to condensed milk, 150, 153 

etiology of, 227 

exercise in, 242 

from faulty nutrition, 227 

geographical distribution of, 228 

histology of, 231 

hygiene in, 241 

in lions, 228 

mortality from, 698 

pathology of, 229 

prognosis of, 239 

prophylaxis of, 239 



Rickets, skull in, 77, 235, 245 

symptoms of, 232, 233 

treatment of, 240, 242, 444 
Rigidity in sclerema, 136 

muscular, 848 
"Ring of Waldeyer," 396 
Ringworm, epidemic, 595 

of body, 596 

of scalp, 594, 599 
Ritter's disease, 602 
Romberg's sign, 837 
Rosary, rachitic, 233, 245 
Rotch on infant feeding, 165, 172 
Rotheln, 653. See also Rubella. 
Roux coccus, 686 

Rubber nipples, 183, 223, 254, 283 
Rubella, 653 

complications of, 656 

diagnosis of, 655 

enanthem in, 655 

eruption of, 634, 654 

etiology of, 653 

rash in, 654 

simulating measles, 648 

stages of, 654 

virus of, 654 
Rubeola, 634. See also Measles. 
Russian mineral oil, 330 



S 



Sacrum, swelling over, 101 
Saint Anthony's dance, 841 

Vitus' dance, 841 
Saline injections, rectal, 304 

irrigations, 292 

purgatives, 383 
Saliva, 184, 185 _ 

pneumococci in, 414 
Salivation, 256, 746 
Salt bath, 850 

fever, 201 
Salts, soluble, 190 
Salvarsan, 746 
Santonin, 345, 347 
Sarcoma of kidney, 555 

of spleen, 495 

of testicle, 574 
Scabies, 604 

differentiated from pediculosis, 604 

with eczema, 587, 604 
Scalp, boils on, 592 

eczema of, 587, 588 

infection of, 72 

lymphangitis, 615 

pocks in, 640 

ringworm of, 594 

seborrhea of, 204 

swelling of, 595 
Scapula, loose-winged, 800 
Scarification, 364 
Scarlatina. See Scarlet Fever. 
Scarlet fever, 628 

albuminuria in, 634 

as air-borne disease, 628 



INDEX 



893 



Scarlet fever, cause of nephritis, 541 
complications in, 634 
contact with, 629, 636 
convalescence from, 638 
cultures in, 633 
desquamation in, 629, 632 
diagnosis of, 633 
differentiated from measles, 648 
from rubella, 655 
from smallpox, 710 
diphtheria in, 634 
ear disease in, 635 
eruption in, 628, 631 
etiology of, 628 
family predisposition to, 628 
faucitis of, 671 
heart affections in, 635 
hemorrhagic, 636 
incubation in, 631 
inoculation, 629 
invasion of, 631 
leukocytosis in, 475 
malignant, 636 
membrane formation in, 662 
mortality in, 698 
nephritis in, 631, 634 
nervous affections in, 635 
pathology of, 630 
pneumonia in, 635 
prophylaxis, 636 
protozoon, 629 
rash, 630, 631 

simulated by serum rash, 682 
spread by milk, 143 
stages in, 631 
susceptibility to, 628 
throat in, 631, 634, 637, 671 
transmission of, 630 
treatment of, 636 
virus of, 628 
white line in, 633 
Scars from eruptions, 741 
Schaudinn's spirochseta, 738, 744 
Schick reaction, 674, 682 
School children, anemic, 464 

detention from, 636, 652, 673, 692, 

845 
hygiene, 29 

life, as taxing child, 29 
nurses, 66 
Schools, diphtheria in, 661 
masturbation in, 860 
measles in, 644 

medical inspection of, 28, 66, 729 
morbidity statistics of, 856 
Schron's capsules, 718 
Schultz's sign in tetany, 849 
Sclera, pigmented, 374 
Sclerema, 135 

distinguished from sclero-edema, 137 
mortality from, 698 
Sclero-edema, 136 

prophylaxis of, 137 
Sclerosis of spinal cord, 804 
Scoliosis, 229, 238 

in muscle atrophy, 796 



Scoliosis in torticollis, 88 
Scorbutus, 763. See Scurvy. 
Scrofula due to teething, 224 
Scrotum, absence of testicle in, 98 
enlargement of, 573 
in hernia, 359 
Scurvy, 763 

beef juice in, 177 
bone changes in, 765 
diagnosis of, 767 
diet a cause of, 764 
differentiation of, 238, 767 
etiologv of, 763 

from sterilized milk, 145, 147, 332 
fruit juices in, 767, 768 
heated food in, 764 
hemorrhages in, 763, 764 
in nephritis, 540 
morbid anatomy in, 764 
raw milk in, 764 
simulated by hemophilia, 488 
stomatitis in, 256, 257 
symptoms of, 765 
tenderness in, 765 
treatment of, 767 
Sea bathing for alopecia, 599 
for miliaria, 593 
food, 589 
salt baths 242 
Seborrhea, 18, 593 
Secrctagogues in food, 187 
Secretions, gastric, 197 
of testicles, 859 
placental, 117 
Seminal emissions in child, 859 
Senna for constipation, 330 
Sense of smell, 395 
Senses, control of, 829 

development of, 43, 771 
Sensory examination, 774 
Separator, cream, 169 
Sepsis as cause of hemorrhage, 130 

rash of, 648 
Septic infection of newborn, 120, 123 
prophylaxis of, 124 
treatment of, 124 
Septicemia, intestinal, 335 

meningococcic, 818 
Septum, intraventricular, 464 

nasal, 391 
Serum, antimeningococcic, S13 
antistreptococcic, 132, 638 
for influenzal meningitis, 814 
Flexner's, 818 
human, 316, 489 
injections, 810 
pneumococcus, 422 
rashes, 648, 680, 681, 682 
therapy, 131, 422 

in cancrum oris, 259 
in diphtheria, 677 
in influenzal meningitis, 707 
in scarlet fever, 638 
Sex a factor in chorea, 842 
in pertussis, 692 
doubtful, 104 



894 



INDEX 



Sex hygiene, 584 
Sexual apathy, 571 

development, 514 

disturbances, 514 

instinct, 852 

organs, abnormality of, 516 
manipulation of, 577 
Sheep, adrenal gland of, 515 

thyroid, desiccated extract of, 513 
Shiga bacillus, 289, 333 
Shingles, 597 
Shock, emotional, 509 

operative, 380 
Shoes for children, 23 
Shoulder, right, pain in, 379 

subluxation of, 109 
Sick-room disinfection, 637 

house-cleaning of, 693 

in diphtheria, 673, 675 
Side, fixation of, 436 
Sight, defective, 830 
Sinus, perpetual, 519 

pleural, 438 

thrombosis, 610, 809 
Sinusoidal current, 794 
Skeleton, changes in, at puberty, 857 
Skin, bran-like, 632 

burrows in, 604 

changes at puberty, 857 

clammy, 424 

crusts on, 591 

desquamation of, 602, 630, 637 

destruction, 741 

diseases of, 586 

congenital, 586, 600 
from teething, 224 
parasitic, 603 

exudate in, 137, 545 

gangrene of, 601 

glossy, 839 

hemorrhage into, 489 

in Addison's disease, 515 

in pseudoleukemia, 481 

in sepsis of newborn, 122 

in syphilis, 744 

induration of, 136 

lesions in indigestion, 318 

maceration of, 590 

of cretins, 511 

of idiots, 835 

of newborn infant, 17 

papery, 590 

pigmentation of, 375, 509 

rashes of, from drugs, 606 

resembling armor, 589 

test, tuberculosis, 297 

trauma of, 586 

ulceration of, 101 

white areas of, 5T5 

yellowness of, 369 
Skull, bosses on, 231, 522 

deformity of, 138 

hot cross bun, 235 

malformation of, 72 

microcephalic, 831, 833 

of newborn infant, 18 



Skull, thin areas on, 2.34 
Sleep in childhood, 29 

in infancy, 23, 160, 770 

importance of, 461 
Sleeplessness, 397, 439 
Smallpox, 707 

abortive, 710 

cause of, 708 

confluent, 708, 709 

contagion of, 707 

crust formation in, 712 

differentiation of, 710 

discrete, 708 

disfigurement from, 712 

eruption of, 709 

etiology of, 707 

hemorrhagic, 708 

history of, 707 

immunity to, 707, 717 

inoculation, 714 

modified by vaccination, 710 

mortality of, 717 

pathology of, 708 

pustules in, 707, 710 

simulated by adrenal disease, 514 
by varicella, 641 

symptoms of, 708 

umbilication of, 709 
Smegma, 575, 859, 860 
Smell, sense of, development of, 44 
Snake poison, 489 
Sneezing, disease conveved by, 815 
Snow, C0 2 , 600 
Snuffles, 397, 741 
Soap-stools, 197, 199, 208, 268 
Social service in hospital, 166 

status and infant mortality, 52 
Sound, vesical, 569 
Spasm, esophageal, 827 

habit, 330 

laryngeal, 507 

muscular, in infancy, 305 
in rickets, 233 

myotonic, 802 

of anus, 366 

of glottis, 400 

of tetanus, 133 

pyloric, 308 

tonic, in tetany, 847 

vesical, 568 

in cystitis, 567 

with dyspnea, 503 
Speech, absence of power of, 85 

development of, 44, 771, 830 

exercises, 85 

impairment of, 84, 398, 805 

nasal, 669 
Spermatic cord, thickening of, 574 

torsion of, 572 
Spermatozoa, 853, 855 

tubercle bacilli in, 719 
Sphincter ani, dilation of, 366 
tonicity of, 364 

hyperirritability of, 301 

relaxation of, 290 

vesicae, 535, 537 



INDEX 



895 



Spina bifida, 100 

cystica, 779 
occulta, 101 
operation for, 103 
rupture of, 100, 101 
Spinal caries, 552 

column, fissure in, 102 
cord, cavity in, 803 

compression of, 781, 806 
degeneration of, 804 
diseases of, 778 
inflammation of, 779 
malformations of, 72, 778 
of newborn, 43, 769 
prolapse of, 101 
tracts of, 770 
tumors, 806 
fluid, albumin in, 776 
bacteria in, 778 
cellular elements in, 778 
dextrose in, 777 
examination of, 776 
bacteriological, 778 
chemical, 776 
cytological, 777 
French method, 777 
physical, 776 
serological, 777 
Fehling's reduction of, 777 
findings in, 817 
pressure of, 776 
Wassermann reaction in, 777 
meningocele, 100 
Spine, curvature of, 24, 236, 238, 552, 
857 
development of, 35 
rigidity of, 552, 782 
Spirochseta pallida, 738, 744 
Spleen, abscess of, 494 
amyloid, 384 

diseases of, mortality from, 698 
enlargement of, 230, 373, 493 
in diphtheria, 668 
in leukemia, 480 
in malaria, 732, 738 
in pseudoleukemia, 481 
new growths of, 495 
nodular, 495 
rupture of, 494 
size of, 493 
syphilitic, 742 
tubercles in, 728 
wandering, 494 
Splenectomy, 483, 502 
Splenic anemia, 502 

blood picture in, 483 
Splenitis, 493 

Splenomegaly, primary, 495 
Spondylitis tuberculosa, 728, 781 
Sprue, 253. See also Thrush. 
Sputum, bloody, 407 

in lobar pneumonia, 417 
rusty, 417 
swallowing of, 425 
tubercle bacilli in, 719 
Stable fly, 785 



Stagnation in stomach, 311 

venous, 315 
Staining, methods of, 657 
Staphylococcus a cause of impetigo, 591 

pyogenes aureus in bone disease, 517 
Starch, digestion of, 149, 176, 193, 197 

in diet of indigestion, 319 

in infant feeding, 156, 179 

indigestion, 271 
Stare in idiocy, 833 
Starvation from indigestion, 199 

in gastritis, 278 

thymus gland in, 504 
Status lymphaticus, 497, 507 

in thymic disease, 502, 504 
treatment of, 508 
Steapsin, action of, 191, 193 
Steno's duct, 699 
Stenosis, aortic, 454 

hypertrophic, 308 

larvngeal, 401, 407, 444 

mitral, 459, 463, 857 

of esophagus, 88 

pulmonary, 451, 453 

tracheal, 507 
Sterilization of food, 196 

of milk, 144, 147, 283 
Sternocleidomastoid muscle, trauma of, 

41, 87 
Sternum, sinking of, 766 
Stick reaction, 730 
Stigmata of degeneration, 831 
Stillbirths, 51, 55, 106, 107 

syphilitic, 745 
Stillborn infants, kidneys in, 111 
Still's disease, 758, 760, 761 

simulating rheumatism, 758 
Stimulation, faradic, 790 

galvanic, 790 

in diarrhea, 286 

in dysentery, 292 

in gastric dilatation, 301 
hemorrhage, 316 

sensory, 772 
Stitch in the side, 747 
Stomach, absorption in, 190 

ballooned, 299 

capacity of, 44, 186, 300 

contents, acidity of, 187 
in the breast-fed, 45 

dilatation of, 299 

symptoms of, 299 
treatment of, 300 

diseases of, 263 

emptying of, 45, 190, 311 

hemorrhage from, fatal, 316 

inflammation of, 295 

motor function of, 187 

perforation of, 316 

position of, 44, 186, 263 

reaction of, at birth, 45 

size of, 45 

tapeworm ova in, 343 

ulcer of, 314 
round, 477 

washing, 275, 298, 304 



896 



INDEX 



Stomach-tube, 275, 278, 838 
Stomatitis, aphthous, 252, 253 

catarrhal, 251, 253 

causes of, 223 

gangrene, 257, 258, 649 
organisms in, 258 
treatment of, 259 

herpetic, 252 

in measles, 649 

mercurial, 388 

mycotic, 255 

ulcerative, 255, 672 
Stone in bladder, 569 

renal, 527 
Stools as index to diet, 319 

bacteria in, 332 

black, 211 

bloody, 129, 315, 324 

bulk of, 209 

color of, 100, 210, 273 

disinfection of, 343, 345 

dry and hard, 326 

fat in, 155 

formation of, 195 

from cow's milk, 195 

green, 269 

hookworm ova in, 349 

in ileocolitis, 321 

in jaundice, 370, 371, 374 

in liver disorders, 381 

in protein indigestion, 201 

in pyloric stenosis, 306 

in summer diarrhea, 281, 284 

normal, 194, 273 

number of, 195 

odor of, 273. 

of dyspepsia, 206 

rice-water, 210 

training concerning, 330 

white, 375 
Straining at stool, 327 
Strength, conservation of, 428 
Streptococcic meningitis, 812 
Streptococcus as cause of scarlet fever, 
629 

diphtheria, 686 
Stricture of anus, 326 
Stridor, laryngeal, 401, 405, 406 
Stupor in meningitis, 811, 816, 821 

in nephritis, 543 
Subarachnoid space, drainage of, 824 
Succus entericus, 192 
Sucking, 44, 85 

interference with, 184 
Sudamina, 593 
Suffocation, 666 

due to foreign body, 408 

in bronchitis, 411 
Sugar, assimilation of, 292 

fermentation of, 173 

fever, 201 

in milk, 156 

in percentage formulas, 173 

in urine, 530 

indigestion, 269 

intoxication, 201 



Sugar of milk, indigestion from, 269 
Sugars as cause of dyspepsia, 206 

digestion of, 193 
Summer diarrhea, 279, 281, 284 
purgation in, 286 
infant mortality in, 56, 61 
Sunlight, 637 

Suppositories, cocaine, 286 
glycerin, 328 
use of, 328 
Suppuration in dactylitis, 521 
Suspensory in urethritis, 571 
Sutures, cranial, ossification of, 35 
Swallowing, difficult, 684, 699 
Sweat ducts, clogging of, 593 

glands, 513, 559, 593 
Sweating, excessive, 237, 723 
Sweats, night, 732 
Sweets, excessive use of, 320, 385 
Sydenham's chorea, 841 
Synovitis, purulent, 522 
Syphilides, varieties of, 590, 594, 711, 

740, 741 
Syphilis, 738 

acquired, 738 
albuminuria in, 743 
bone changes in, 742, 745 
cause of alopecia, 598 
of craniotabes, 521 
of hemoglobinuria, 527 
congenital, 234, 387, 388 
conveyed by virus, 716 
early, 743 

eruption of, 738, 743 
hereditary, 127, 739 

bone changes in, 519 
cause of nephritis, 547 
enlarged spleen in, 495 
late, 745 
idiocy in, 832 

infection in, sources of, 738 
joints in, 744 
lesions of, at puberty, 742 

tertiary, 739, 746 
nervous system in, 743 
nutrition in, 746 
of bone, 520 
of liver, 387 
paralysis due to, 109 
specific organism of, 738 
symptoms of, 738 
therapeutic test in, 297 
transmission of, 739 

seminal, 739 
treatment of, 745 
by mercury, 745 
local, 746 
Syringomyelia, 803 



Tabes, juvenile, 805 
Tache cerebrale, 724, 816 
Tachycardia, 447 
in goitre, 509 



INDEX 



897 



Tactile sensation at birth, 21 

sense tracts, 43, 44 
Tamiae, 341 

echinococcus, 389 

mediocanellata, 342 

nana, 342 

solium, 342 
Talipes equinovarus, 805 

equinus, 801, 848 
Talking, backwardness in, 140 
Tapeworm, beef, 341, 342 

dwarf, 342 

fish, 342 

expulsion of, 343 

pork, 341, 342 

segments of, 343 

stools, 343 

symptoms of, 343 

treatment of, 343 
Tartar, 225, 260 
Taste, sense of, development of, 44 

in newborn, 21 
Taxis for hernia, 361 
Teeth, brushing of, 249, 250 

caries of, 221, 225 

defective, 222 

deficiencv of, 221 

eruption of, 185, 220 

extraction of, 250 

gritting of, 232, 341, 345, 347 

Hutchinson's, 743, 745 

irregularity of, 222 

milk, 220 

natal, 220, 221 

notched, 745 

permanent, 218, 221 
Teething, diagnosis of, 221 

theories concerning, 217 
Temperature, high, cause of diarrhea, 331 
continued, 419 

in appendicitis, 337 

in bronchopneumonia, 425 

in cholera infantum, 294 

in ileocolitis, 288 

in infancy, 40 

in lobar pneumonia, 417 

in measles, 645 

in nephritis, 543 

in sepsis of newborn, 122 

of newborn, 21 

of nursery, 23, 25 

outdoor, maximum of, 41 

subnormal, 41 

variations in, 40 
Tendon transplantation, 802, 828 
Tenesmus, rectal, 362, 366 
Tents, treatment of wounds in, 216 
Tenotomy, 802, 828 
Test, cutaneous, 730 

electrical, 773 

Fehling's, 531 

fermentation, 531 

for bile, 370 

for indican, 530 

meal in gastritis, 297 

sensory, 774 
57 



Test, tuberculin; 499, 519, 823 

uric acid, 528 
Testes, atrophy of, 700 

undescended, 97, 98, 572, 859 
Testicle, cystic disease of, 574 

descent of, 358 

excision of, 572, 859 

injury to, 573, 574 

sarcoma of, 574 

suppuration of, 573 

tuberculous, 728 

tumors of, 574* 
Testicles at puberty, 855 

position of, 359 
Tetanus, 133 

differential diagnosis of, 134 

epidemic, 134 

etiology of, 133 

symptoms of, 133 

treatment of, 134 
Tetany, 846 

among the poor, 847 

from malnutrition, 849 

hygiene in, 850 

hysterical, 847 

in rickets, 244 

phenomena in, 848 

postmortem findings, 847 

toxic, 847 

treatment of, 849 
Thermometer, bath, 22 
Thermometers, use of, 361 
Thigh rubbing, 582 
Thirst in dysentery, 290 

in gastric dilatation, 300 

in gastritis, 276, 277 
Thomsen's disease, 802. See also Myo- 
tonia Congenita. 
Thorax in asthma, 441 

of newborn infant, 18 

size of, 34, 36 
Threadworm, 341, 344 

treatment of, 346 
Thrill, cardiac, 453, 454 
Throat, cultures from, 671 

in diphtheria, 659 

in scarlet fever, 631, 634 

inflammation of, 687 

septic infection of, 648 

sore, rheumatic, 747, 751 

swabbing of, 675 
Thrombus, cardiac, 668 
Thrush, 250, 253 

in chronic gastritis, 296 

in cleft palate, 85 

treatment of, 255 
Thumb-sucking, 222 
Thymectomy, 508 
Thymic death, 506 

stridor, 505, 507 
Thvmol for hookworm disease, 349 
Thvmus gland, 35, 499 

atrophy of, 499, 504 
cervicothoracic, 501 
conglomerate, 502 
enlarged, 115, 441, 504 



S9S 



INDEX 



Thymus gland, enlarged, conglomerate 
thoracic, 505 
extirpation of, 36, 502 
function of, 36, 501 
hyperplasia of, 504 
in idiots, 502 
in marasmus, 36 
in newborn, 20 
lobes of, 499 
operations on, 508 
percussion of, 504 
physiology of, 501 
regression of, 500 
thoracic, 500, 503 
variations in, 502 
weight of, 499, 504 
Thyroid extract for adiposity, 516 
for enuresis, 537 
for macroglossia, 86 
gland, diseases of, 508 

enlarged at puberty, 854 
grafting of, 513 
in mumps, 700 
in newborn, 20 
secretion of, 510 
size of, 513 
use of, 249, 513 
Thyroidectin, 509 
Thyroidectomy, partial, 509 
Thyroiditis, 510 
Tic tac, fetal, 456 
Tinea circinata, 596 
tonsurans, 595 
Tinnitus aurium, 849 
Tissues, waste of, 154 
Toes, gangrene of, 649 
clubbing of, 452, 454 
necrosis of, 521 
Toilets, separate, 578 
Tongue, diminutive, 249 
diseases of, 248 
hemangioma of, 86 
hypertrophy of, 249, 835 
in scarlet fever, 630, 631 
lymphangioma of, 86 
of cretin, 249 
protruding, 248 
strawberry, 634, 656 
swallowing of, 249 
Tongue-tie, 85 
Tonsillitis, croupous, 686 
follicular, 671 

simulating diphtheria, 659 
in chorea, 841 
rheumatic, 747, 751 
Tonsils, disease of, 397 

a cause of adenitis, 496 
enlarged, 438, 537 
gangrene of, 634 
hyperplasia of, 399 
in scarlet fever, 671 
removal of, 757 
tumor formation in, 396 
Tooth-germ, destruction of, 221 
Tooth-sockets, necrosis of, 256 
Torsion of spermatic cord, 572 



Torticollis, 41, 757 

congenital, 87 

operation for, 87, 88 
Toxemia, cause of urticaria, 589 

chronic, 504 

from worms, 347 

in diphtheria, 676 

in pneumonia, 417 

intestinal, 92, 282, 335, 849 
Toxins, absorption of, 318 

cause of myocarditis, 469 

excretion of, 539 
Toxone, 678 

Touch, sense of, development of, 44 
Trachea, compression of, 500, 505 

dilatation of, 685 

diphtheritic exudate in, 683 
Tracheotomy, 402, 403 

diphtheritic infection in, 667 

for foreign body, 408 

in diphtheria, 682 

in thymic disease, 508 

indications for, 685 

tube, 683 
Training of children, 93 
Traits, hereditary, 856 
Transfusion of blood, 127, 129, 131, 

489 
Transillumination of stomach, 300 
Transmission of characters, 69, 70 

of disease, 69, 163, 487 
Traube's space, 460, 466 
Trauma a cause of intussusception, 
323 
of meningitis, 820 
of splenitis, 494 
Tremor, intention, 826 

muscular, 509 
Trephining of skull, 828 
Trichina spiralis, 350 
Trichiniasis, 350 
Trichocephalus dispar, 347 
Tricuspid insufficiency, 463 
"Trichter-brust," 37 
Trismus neonatorum, 133 
Trophic disturbances, 826, 827 
Trousseau's phenomenon, 774, 848 
Truss for hernia, 360 

for hydrocele, 99 
Trypsin, action of, 191 
Tub bath for infants, 22 
Tube, rectal, 626 

Tubercle bacillus, 717, 719, 721, 722 
bovine, 718, 819 
cause of adenitis, 498 
of caries, 781 
of meningitis, 819 
of peritonitis, 354 
in skin, 606 
in urine, 554 

encapsulation of, 722 

formation of, 721 

in kidney, 728 

in liver, 387 

miliary, 722 

in brain, 820 



INDEX 



Tuberculin, care in use of, 732 
reaction, 499, 519, 823 
tests, 729, 731 
Tuberculosis, 717 

acute, forms of, 723 

miliary, differentiated from 
tvphoid, 624 
alimentary, 718, 720 
at puberty, 857 
auscultation in, 724, 725 
autopsy reports on, 721 
bone, 518 

bovine, 718, 719, 819 
carriers of, 720 
chronic, 725 

diagnosis of, 725 

symptoms of, 725 
complicating; chlorosis, 477 
congenital, 719 
cough in, constant, 726 
cutis, 606 
diet in, 731 

differentiated from peritonitis, 355 
emaciation in, 724 
etiology of, 717 
general, 722, 726 

and orchitis, 573 

kidneys in, 553 
glandular, 727 

bronchial, 726 
hereditary, 719 
in Addison's disease, 515 
incidence of, 721 
latent, 719, 720 

in measles, 651 
lesions of, 721 
leukocytes in, 475 
meningeal, 723 
miliary, 386, 722 
modes of acquiring, 720 
of cervical lymph nodes, 498 
of intestines, 728 
of joints, 523 
of liver, 386 
of pleura, 727 
pathology of, 719, 721 
placental, 719 
predisposition to, 852 
prognosis of, 728 
prophylaxis of, 729 
pulmonary, 722 
renal, 553 
tests for, 729 
transmission of, 719 
treatment of, 731 
typhoid form of, 723 
ulcerative papillomatous, 606 
Tuberculous adenitis, operation for, 
499 
meningitis, 819 

chronic, 822 

spinal, 822 
Tumor, abdominal, 558 
at root of tongue, 403 
bloody, 78 
cerebellar, 805 



Tumor, cervical, 102 
extramedullar, 806 
fecal, 494 
in iliac fossa, 338 
intramedullary, 806, 807 
intrameningeal, 801 
laryngeal, 406 
lumbosacral, 101 
of brain, 72 
of kidney. 554 
of liver, 388 
of neck, 87 
of pineal gland. 516 
of pituitary gland, 516 
of pylorus, 302. 305 
of rectum, 365 
of spinal canal, 100 
of umbilicus, 89 
pedunculated, 365 
Tumors, benign and malignant. 555 
sessile, 365 
spinal cord, 806 
Tunica vaginalis, 358 

hydrocele of, 98 
Turbinates, deformity of, 391 

swelling of, 394 
Turpentine stupe, 626 
Tympanites, 201, 425. 626 
Tympany, gastric, 300 
Typhoid bacilli, 617, 618 

in cow's milk, 143 

in stools, 623 
fever, 617 

abortive, 620 

alcohol in. 627 

blood in, 623 

complications of. 624 

constipation in, 626 

diet in, 625 

differentiation of, 623 

disinfection in, 617, 625 

etiology of, 617 

feces. 625 

heart in, 470 

hemorrhage in, 627 

herpes in, 246 

hydrotherapy in. 626 

in fetus, 61S 

in older child, 620 

incubation in, 618 

infantile, 619 

miscarriage during, 618 

mortality in, 624, 698 

pathology of, 618 

perforation in, 620, 627 

pulse in, 620 

relapses, 623 

temperature, 620, 621 

treatment of, 625 
by fresh air, 213 

urine in, 625 
meningitis, 813 
state, 724 
tuberculosis, 723 
vaccine, 625 
Typhus, treatment of, 216 



900 



INDEX 



U 



Uffelm ann's milk granules, 195, 209 
Ulcer, follicular, 290, 315 

gastric, 314, 315 

in rectum, 362 

of enterocolitis, 287 

of labia, 580 

of mouth, 247, 252 

of skin, 601 

tuberculous, 315 
Ulceration, corneal, 224 

of gastric mucosa, 276 

of palate, 250 

of prolapsed rectum, 363 

of skin, 101 

of tongue, 250 
Umbilical cord, asepsis of, 134 
compression of, 113 
tumor of, 90 

vein, bacilli in, 618 
Umbilication of vesicles, 640, 641 
Umbilicus, diseases of, 124 

discharge from, 89 

gangrene of, 125 

hemorrhage from, 125 

hernia of, 90, 95 

infection of, 120, 128, 522 
Uncinariasis, 349 
Undernourishment, 204 
Urachus, fistula of, 89 
Urea, diminution of, 550 
Uremia, anuria in, 533 

hot packs for, 637 

in kidney cysts, 558 

in nephritis, 543, 544 
Ureter, clots in, 556 

obstruction of, 563 
Urethra, atresia of, 103 

bleeding from, 527 

deformity of, 104 

irrigation of, 571 

stone in, 555 
Urethral caruncle, 532 

granulations, 532 
Urethritis, diet in, 571 

gonorrheal, 570 

in the sexes, 570 

purulent, 531 

specific, 570 
Uric acid crystals, 528 

infarcts, 111, 533 
Urinalysis, 544 
Urine, alkalinity of, 537 

bile in, 100, 370, 374, 375 

blood in, 527, 569 

color of, 375, 526 

dribbling of, 96, 104, 535, 567, 569 

examination of, 537 

feces in, 94 

in bronchopneumonia, 425 

in chorea, 843, 846 

in gastritis, 276 

in jaundice, 119 

in nephritis, 540, 548 

in pneumonia, 418 



Urine in renal tuberculosis, 554 
in rickets, 232 
in typhoid, 623 
microscopic study of, 526 
normal, 525 

acetone in, 529 

glucose in, 530 

indican in, 530 

quantity of, 525 

specific gravity of, 526 
of newborn, 111 
pigment in, 100, 527 
pus in, 531 

reaction of, 526, 566, 568 
retention of, 532 
sero-albumin in,' 527 
smoky hue of, 526 
specimen of, 525 
sugar in, 530 
suppression of, 532 

due to drugs, 533 

for ten days, 544 
tubercle bacilli in, 565 
uric acid in, 568 
Urobilin, increase in, 371 
Urotropin in infantile paralysis, 794 
Urticaria, 588 

in purpura, 492 
Uvula, elongation of, 260. 438 

puncture of, 261 
Uvulitis, 260 



Vaccination, 715 

contraindications for, 717 

eruption of, 713 

fatal, 716 

history of, 714 

mark, 713 

modifying smallpox, 710 

preferable time for, 27 

repetition of, 716 

transmission of disease by, 716 

value of, 717 
Vaccine therapy in cystitis, 568 
in erysipelas, 132 
in furunculosis, 592 
in otitis, 612 
in pertussis, 697 
in pyorrhea alveolaris, 260 

typhoid, 625 

virus, 714, 716 
Vaccines, autogenous, 422, 612, 614, 818 

mixed, 697 

stock, 580, 612 
Vaccinia, 713 

inoculation with, 714 

in United States, 714 

symptoms of, 715 
Vagina, inflammation of, 577 
Valves, deformity of, 452, 453- 
Valvular disease, acquired, 461 
Vapor baths, 546 

inhalation of, 686 



INDEX 



901 



Varicella, 639 

bullosa, 640 

complications of, 641 

diagnosis of, 640 

differentiation of, 641, 711 

eruption of, 639, 641 

gangrenous, 640 

hemorrhagic, 640 

immunity from, 639 

scratching in, 642 

symptoms of, 639 

treatment of, 641 
Variola, 707. See also Smallpox. 

hemorrhagica, 70S, 710 
pustulosa, 709 

vera, 708 
Variolar sine variolis, 710 
Varioloid, 708, 710 

complications of, 711 

diagnosis of, 710 

disinfection in, 712 

eruption in, 712 

isolation in, 712 

mortality in, 711 

prognosis in, 711 

treatment of, 712 
Vasomotor system, 857 
Vegetable juices in scurvy, 768 

proteins, 177 
Vegetables, raw, infection through, 289, 

617 
Vein, umbilical, obliteration of, 39 
Venous hum, 450 

obstruction, 452 
Ventilation, 651 
Ventricle, hypertrophy of, 455 

lateral, distention of, 75 
Ventricular septum, defect in, 451 
Vermifuge, 344, 347 
Veronal in pertussis, 694 
Verrucae planus juvenilis, 598 

vulgaris, 598 
Vertebrae, caries of, 781 
Vesical calculi, composition of, 569 
operations for, 569 

spasm, 568 
Virus, vaccine, bovine, 714, 715 

humanized, 714, 716 
Visiting nurse, 57 

physician, 57 
Vocal cords, false, 405 
tumors on, 406 

fremitus, 415, 434 
Voice, absence of, 435 

in diphtheria, 666 

after emasculation, 854 

change in, 262, 406 

cracking of, 854 

nasal, 84, 660 
Volvulus, 335 
Vomiting after meals, 296 

as sign of obstruction, 94 

cyclic, 198, 265, 312, 529 

due to malformation of esophagus, 
88 

habitual, 263, 303, 307 



Vomiting in infancy, 263, 452 

in meningitis, 816 

in" neurotic child, 265 

in pyloric stenosis, 306 

in pylorospasm. 302 

in pyrexia, 204 

in summer diarrhea, 281 

in newborn, 94 

in tuberculous meningitis, 821 

of blood, 129, 315 

persistent, 324 

projectile. 204 

reflex, 264 

stercoraceous, 334 

symptomatic, 263 
Vomitus of cholera infantum, 293 

of chronic gastritis, 296 

of gastric indigestion, 274 
von Jaksch, pseudoleukemia of. 481 
I von Pirquet reaction, 322. 353. 521, 523, 

730, 731, 744, 823 
Vulva, excision of. 580 

gangrene of, 580 
Vulvovaginitis. 575 

cause of peritonitis, 353 

epidemic, 576 

gonorrheal, 575. 578 

treatment of, 579 



W 



Walking, 24, 42, 106 

chair, 794 
Wart-pox, 710 
Warts, 597. See also Verruca?. 

contagious, 602 

removal of, 598 
Wassermann reaction, 388, 520, 521, 523, 

591, 744, 777 
Waste, elimination of, 153 
Wasting from melena, 131 
Water as a diluent, 149 

bed, 818 

boiling of, 617 

contaminated, 289 
worms from, 348 

in ears, 607 

in fevers, 712 

infant's need of, 153, 280, 428 

ingestion of, 31, 153, 283, 328 
excessive, 534 
Weaning, 162, 239 

during teething, 219 

feeding after, 183, 317 

in summer, 283 

partial, 164 

temporarv, 164 

time for, "l'63, 239 
Weichselbaum's diplococcus, 814 
Weight chart, 32 

curve, decline in, 205 

fluctuations in, 198 

gain in, 152, 853 

increased by carbohvdrates, 157 

loss of, 159, 207, 294, 317 



902 



INDEX 



Weight, normal. 33 

of boys, 30 

of infants, 30, 31 

scales, 33 

significance of, 323 

stationary, 31, 33, 268 
Weil's disease, 371 
Wet-nurse, 165, 268, 269, 271 

infection of, 740 

necessity for, 285 

selection of, 166 

syphilitic, 164, 746 
Whey, 174, 175 

cream mixture, 285 

in gastro-intestinal diseases, 176 

proteins, 202, 272 
Whipworm, 347, 348 
White line on ringer, 656 
Whooping-cough, 688. See also Pertussis. 
Widal reaction, 420, 619, 623, 624 
Will, weakness of, 860 
Winckel's disease, 128, 130, 371, 527 
Winking, optical reflex of, 43 
Wolffian body, 557 
Worms, intestinal, 341 

among the poor, 341 
treatment of, 345 

pin, 344 

round, 341, 346, 347, 378 

seat, 344, 582 



Worms, thread, 341, 344 
Wounds, diphtheria in, 667 
Wrist, broad, in rickets, 236 



X-rays in diagnosis, 435 

of enlarged thymus, 508 
of foreign body, 408 
of renal calculi, 555 
■ of spinal disease, 87 
of torticollis, 87 

in ear disease, 615 

in enlarged lymph nodes, 439 

in locating colon, 93 

in lymphatic anemia, 487 

in pericarditis, 466 

in psoriasis, 594 



Yellow atrophy of liver, 37! 



Zappert's records, 793 
Zygoma, sign over, 849 



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